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Surgery_Schwartz_12902 | Surgery_Schwartz | occlusive disease affecting small and medium-sized arter-ies and veins. It is strongly influenced by smoking and will often resolve upon smoking cessation. The disease is classified into acute, intermediate, and chronic, depending on histologic progression of the disease. Migratory phlebitis occurs distal to the elbow, resulting in ischemia, rest pain, and ulceration and necrosis of the digits. It can continue to cause more proximal ischemia and ultimately lead to loss of the hands. Treatment must start with smoking cessation. Failure to stop smoking will make any surgical intervention unsuccessful. Arteriography is useful to determine arterial flow and whether bypass is possible. ABFigure 44-31. Z-plasty release of web space contracture. A. First web space burn contracture. B. Immediate postoperative result.Brunicardi_Ch44_p1925-p1966.indd 196020/02/19 2:50 PM 1961SURGERY OF THE HAND AND WRISTCHAPTER 44If direct bypass is not possible, alternatives include arteriali-zation of the | Surgery_Schwartz. occlusive disease affecting small and medium-sized arter-ies and veins. It is strongly influenced by smoking and will often resolve upon smoking cessation. The disease is classified into acute, intermediate, and chronic, depending on histologic progression of the disease. Migratory phlebitis occurs distal to the elbow, resulting in ischemia, rest pain, and ulceration and necrosis of the digits. It can continue to cause more proximal ischemia and ultimately lead to loss of the hands. Treatment must start with smoking cessation. Failure to stop smoking will make any surgical intervention unsuccessful. Arteriography is useful to determine arterial flow and whether bypass is possible. ABFigure 44-31. Z-plasty release of web space contracture. A. First web space burn contracture. B. Immediate postoperative result.Brunicardi_Ch44_p1925-p1966.indd 196020/02/19 2:50 PM 1961SURGERY OF THE HAND AND WRISTCHAPTER 44If direct bypass is not possible, alternatives include arteriali-zation of the |
Surgery_Schwartz_12903 | Surgery_Schwartz | result.Brunicardi_Ch44_p1925-p1966.indd 196020/02/19 2:50 PM 1961SURGERY OF THE HAND AND WRISTCHAPTER 44If direct bypass is not possible, alternatives include arteriali-zation of the venous system by connecting the dorsal venous network to the brachial artery or possible free microvascular omental transfer beneath the dorsal forearm or hand for indirect revascularization.109Vasospastic DisordersRaynaud’s syndrome results from excessive sympathetic ner-vous system stimulation. Perfusion is diminished and fingers often become cyanotic. Although the onset of the symptoms is benign, chronic episodes can result in atrophic changes and painful ulceration or gangrene of the digits. Raynaud’s disease occurs without another associated disease. This disease predom-inately affects young women and is often bilateral. The vascular system is structurally intact without any obstructions. There is no ulceration, gangrene, or digit loss. In contrast, Raynaud’s phenomenon is associated with an | Surgery_Schwartz. result.Brunicardi_Ch44_p1925-p1966.indd 196020/02/19 2:50 PM 1961SURGERY OF THE HAND AND WRISTCHAPTER 44If direct bypass is not possible, alternatives include arteriali-zation of the venous system by connecting the dorsal venous network to the brachial artery or possible free microvascular omental transfer beneath the dorsal forearm or hand for indirect revascularization.109Vasospastic DisordersRaynaud’s syndrome results from excessive sympathetic ner-vous system stimulation. Perfusion is diminished and fingers often become cyanotic. Although the onset of the symptoms is benign, chronic episodes can result in atrophic changes and painful ulceration or gangrene of the digits. Raynaud’s disease occurs without another associated disease. This disease predom-inately affects young women and is often bilateral. The vascular system is structurally intact without any obstructions. There is no ulceration, gangrene, or digit loss. In contrast, Raynaud’s phenomenon is associated with an |
Surgery_Schwartz_12904 | Surgery_Schwartz | and is often bilateral. The vascular system is structurally intact without any obstructions. There is no ulceration, gangrene, or digit loss. In contrast, Raynaud’s phenomenon is associated with an underlying connective tissue disorder, such as scleroderma. Arterial stenosis is present due to disease changes in blood vessels as a result of the specific medical disorder.110Scleroderma is an autoimmune connective tissue disorder resulting in fibrosis and abnormal collagen deposition in tissue. Many organs can be affected, with the skin most commonly and noticeably involved. In this disease, blood vessels are injured by intimal fibrosis leading to microvascular disease. The ves-sels become subject to Raynaud’s phenomenon, and patients develop painful, ulcerated, and sometimes necrotic digits.109,110Sympathectomy can provide pain relief and healing of ulcers for patients with scleroderma and Raynaud’s phenom-enon. In this procedure, adventitia is stripped from the radial artery, ulnar | Surgery_Schwartz. and is often bilateral. The vascular system is structurally intact without any obstructions. There is no ulceration, gangrene, or digit loss. In contrast, Raynaud’s phenomenon is associated with an underlying connective tissue disorder, such as scleroderma. Arterial stenosis is present due to disease changes in blood vessels as a result of the specific medical disorder.110Scleroderma is an autoimmune connective tissue disorder resulting in fibrosis and abnormal collagen deposition in tissue. Many organs can be affected, with the skin most commonly and noticeably involved. In this disease, blood vessels are injured by intimal fibrosis leading to microvascular disease. The ves-sels become subject to Raynaud’s phenomenon, and patients develop painful, ulcerated, and sometimes necrotic digits.109,110Sympathectomy can provide pain relief and healing of ulcers for patients with scleroderma and Raynaud’s phenom-enon. In this procedure, adventitia is stripped from the radial artery, ulnar |
Surgery_Schwartz_12905 | Surgery_Schwartz | can provide pain relief and healing of ulcers for patients with scleroderma and Raynaud’s phenom-enon. In this procedure, adventitia is stripped from the radial artery, ulnar artery, superficial palmar arch, and digital arter-ies in various combinations based on the affected digits being treated. The decrease in sympathetic tone allows for vasodila-tion and increased blood flow. If the patient notes significant distal pain relief and/or previously ischemic tissue improves in color after a test administration of local anesthetic, sympathec-tomy may provide the same results in a long-term fashion.111 Recently, several studies have investigated the use of botulinum toxin on improving digital perfusion in patients with Raynaud’s. Reports have shown improved objective measurements of hand function 8-12 weeks after injection.112CONGENITAL DIFFERENCESCongenital differences in a newborn can be particularly dis-abling as the child learns to interact with the environment by using the hands. The | Surgery_Schwartz. can provide pain relief and healing of ulcers for patients with scleroderma and Raynaud’s phenom-enon. In this procedure, adventitia is stripped from the radial artery, ulnar artery, superficial palmar arch, and digital arter-ies in various combinations based on the affected digits being treated. The decrease in sympathetic tone allows for vasodila-tion and increased blood flow. If the patient notes significant distal pain relief and/or previously ischemic tissue improves in color after a test administration of local anesthetic, sympathec-tomy may provide the same results in a long-term fashion.111 Recently, several studies have investigated the use of botulinum toxin on improving digital perfusion in patients with Raynaud’s. Reports have shown improved objective measurements of hand function 8-12 weeks after injection.112CONGENITAL DIFFERENCESCongenital differences in a newborn can be particularly dis-abling as the child learns to interact with the environment by using the hands. The |
Surgery_Schwartz_12906 | Surgery_Schwartz | 8-12 weeks after injection.112CONGENITAL DIFFERENCESCongenital differences in a newborn can be particularly dis-abling as the child learns to interact with the environment by using the hands. The degree of anomaly can range from minor, such as a digital disproportion, to severe, such as total absence of a forearm bone. In recent years, increasing knowledge of the molecular basis of embryonic limb development has sig-nificantly enhanced the understanding of congenital differences. Congenital hand differences have an incidence of 1:1500 births. The two most common differences encountered are syndactyly and polydactyly.113There are numerous classification systems for hand dif-ferences. The Swanson classification, adopted by the American Society for Surgery of the Hand, delineates seven groups orga-nized based on anatomic parts affected by types of embryonic failures.114,115Failure of FormationThe failure of the formation of parts is a group of congenital differences that forms as a | Surgery_Schwartz. 8-12 weeks after injection.112CONGENITAL DIFFERENCESCongenital differences in a newborn can be particularly dis-abling as the child learns to interact with the environment by using the hands. The degree of anomaly can range from minor, such as a digital disproportion, to severe, such as total absence of a forearm bone. In recent years, increasing knowledge of the molecular basis of embryonic limb development has sig-nificantly enhanced the understanding of congenital differences. Congenital hand differences have an incidence of 1:1500 births. The two most common differences encountered are syndactyly and polydactyly.113There are numerous classification systems for hand dif-ferences. The Swanson classification, adopted by the American Society for Surgery of the Hand, delineates seven groups orga-nized based on anatomic parts affected by types of embryonic failures.114,115Failure of FormationThe failure of the formation of parts is a group of congenital differences that forms as a |
Surgery_Schwartz_12907 | Surgery_Schwartz | groups orga-nized based on anatomic parts affected by types of embryonic failures.114,115Failure of FormationThe failure of the formation of parts is a group of congenital differences that forms as a result of a transverse or longitudinal arrest of development. Conditions in this group include radial club hand, a deformity that involves some or all of the tissues on the radial side of the forearm and hand, and ulnar club hand, which involves underdevelopment or absence of the ulnar-sided bones.Failure of DifferentiationThe failure of the differentiation of parts comprises conditions where the tissues of the hand fail to separate during embryo-genesis. Syndactyly, in which two or more fingers are fused together, is the most common congenital hand deformity and occurs in 7 out of every 10,000 live births. There is a famil-ial tendency to develop this deformity. This deformity often involves both hands, and males are more often affected than females. Syndactyly is classified as either | Surgery_Schwartz. groups orga-nized based on anatomic parts affected by types of embryonic failures.114,115Failure of FormationThe failure of the formation of parts is a group of congenital differences that forms as a result of a transverse or longitudinal arrest of development. Conditions in this group include radial club hand, a deformity that involves some or all of the tissues on the radial side of the forearm and hand, and ulnar club hand, which involves underdevelopment or absence of the ulnar-sided bones.Failure of DifferentiationThe failure of the differentiation of parts comprises conditions where the tissues of the hand fail to separate during embryo-genesis. Syndactyly, in which two or more fingers are fused together, is the most common congenital hand deformity and occurs in 7 out of every 10,000 live births. There is a famil-ial tendency to develop this deformity. This deformity often involves both hands, and males are more often affected than females. Syndactyly is classified as either |
Surgery_Schwartz_12908 | Surgery_Schwartz | live births. There is a famil-ial tendency to develop this deformity. This deformity often involves both hands, and males are more often affected than females. Syndactyly is classified as either simple (soft tissue only) or complex (bone and/or cartilage also involved), and complete (full length of the digits) or incomplete (less than the full length).Surgical release of syndactyly requires the use of local flaps to create a floor for the interdigital web space and to partially surface the adjacent sides of the separated digits (Fig. 44-32). Residual defects along the sides of the separated fingers are covered with full-thickness skin grafts. Surgery usu-ally is performed at 6 to 12 months of age.DuplicationDuplication of digits is also known as polydactyly. Radial polydactyly is usually manifests as thumb duplication. Wassel described a classification system for thumb duplications based on the level of bifurcation.116 When two thumbs are present in the same hand, they are rarely | Surgery_Schwartz. live births. There is a famil-ial tendency to develop this deformity. This deformity often involves both hands, and males are more often affected than females. Syndactyly is classified as either simple (soft tissue only) or complex (bone and/or cartilage also involved), and complete (full length of the digits) or incomplete (less than the full length).Surgical release of syndactyly requires the use of local flaps to create a floor for the interdigital web space and to partially surface the adjacent sides of the separated digits (Fig. 44-32). Residual defects along the sides of the separated fingers are covered with full-thickness skin grafts. Surgery usu-ally is performed at 6 to 12 months of age.DuplicationDuplication of digits is also known as polydactyly. Radial polydactyly is usually manifests as thumb duplication. Wassel described a classification system for thumb duplications based on the level of bifurcation.116 When two thumbs are present in the same hand, they are rarely |
Surgery_Schwartz_12909 | Surgery_Schwartz | manifests as thumb duplication. Wassel described a classification system for thumb duplications based on the level of bifurcation.116 When two thumbs are present in the same hand, they are rarely both normal in size, alignment, and mobility. In the most common form of thumb duplication, a single broad metacarpal supports two proximal phalanges, each of which supports a distal phalanx. Optimal reconstruction requires merging of elements of both component digits. Usually the ulnar thumb is maintained. If the duplication occurs at the MP joint, the radial collateral ligament is preserved with the metacarpal and attached to the proximal phalanx of the retained ulnar thumb. Surgery is usually performed at 6 to 12 months of age. Ulnar-sided polydactyly may often be treated by simple excision of the extra digit.OvergrowthOvergrowth of digits is also known as macrodactyly, which causes an abnormally large digit. In this situation, the hand and the forearm also may be involved. In this rare | Surgery_Schwartz. manifests as thumb duplication. Wassel described a classification system for thumb duplications based on the level of bifurcation.116 When two thumbs are present in the same hand, they are rarely both normal in size, alignment, and mobility. In the most common form of thumb duplication, a single broad metacarpal supports two proximal phalanges, each of which supports a distal phalanx. Optimal reconstruction requires merging of elements of both component digits. Usually the ulnar thumb is maintained. If the duplication occurs at the MP joint, the radial collateral ligament is preserved with the metacarpal and attached to the proximal phalanx of the retained ulnar thumb. Surgery is usually performed at 6 to 12 months of age. Ulnar-sided polydactyly may often be treated by simple excision of the extra digit.OvergrowthOvergrowth of digits is also known as macrodactyly, which causes an abnormally large digit. In this situation, the hand and the forearm also may be involved. In this rare |
Surgery_Schwartz_12910 | Surgery_Schwartz | of the extra digit.OvergrowthOvergrowth of digits is also known as macrodactyly, which causes an abnormally large digit. In this situation, the hand and the forearm also may be involved. In this rare condition, all parts of a digit are affected; however, in most cases, only one digit is involved, and it is usually the index finger. This condition is more commonly seen in males. Surgical treatment of this condi-tion is complex, and the outcomes may be less than desirable. Sometimes, amputation of the enlarged digit provides the best functional result.Constriction Band SyndromeUnderdeveloped fingers or thumbs are associated with many congenital hand deformities. Surgical treatment is not always required to correct these deformities. Underdeveloped fingers may include the following: small digits (brachydactyly), miss-ing muscles, underdeveloped or missing bones, or absence of a digit.Generalized Skeletal Anomalies and SyndromesThis is a rare and complex group of unclassified | Surgery_Schwartz. of the extra digit.OvergrowthOvergrowth of digits is also known as macrodactyly, which causes an abnormally large digit. In this situation, the hand and the forearm also may be involved. In this rare condition, all parts of a digit are affected; however, in most cases, only one digit is involved, and it is usually the index finger. This condition is more commonly seen in males. Surgical treatment of this condi-tion is complex, and the outcomes may be less than desirable. Sometimes, amputation of the enlarged digit provides the best functional result.Constriction Band SyndromeUnderdeveloped fingers or thumbs are associated with many congenital hand deformities. Surgical treatment is not always required to correct these deformities. Underdeveloped fingers may include the following: small digits (brachydactyly), miss-ing muscles, underdeveloped or missing bones, or absence of a digit.Generalized Skeletal Anomalies and SyndromesThis is a rare and complex group of unclassified |
Surgery_Schwartz_12911 | Surgery_Schwartz | small digits (brachydactyly), miss-ing muscles, underdeveloped or missing bones, or absence of a digit.Generalized Skeletal Anomalies and SyndromesThis is a rare and complex group of unclassified problems.Brunicardi_Ch44_p1925-p1966.indd 196120/02/19 2:50 PM 1962SPECIFIC CONSIDERATIONSPART IIRECONSTRUCTIVE TRANSPLANTATION OF THE UPPER EXTREMITYHand transplantation was first performed in humans in the late 1990s both in Louisville, Kentucky, and Lyon, France.117 The treating surgeons were able to successfully remove an upper extremity from a brain-dead donor, attach it to an upper extrem-ity amputee, and have the tissue survive. In the subsequent 15 years, many additional centers have achieved technical suc-cess with upper extremity transplantation as well.The technical considerations of hand transplantation have proven to be only the beginning of challenges in bring-ing this treatment option to the general public. Replantation of an amputated limb was first reported by Malt in | Surgery_Schwartz. small digits (brachydactyly), miss-ing muscles, underdeveloped or missing bones, or absence of a digit.Generalized Skeletal Anomalies and SyndromesThis is a rare and complex group of unclassified problems.Brunicardi_Ch44_p1925-p1966.indd 196120/02/19 2:50 PM 1962SPECIFIC CONSIDERATIONSPART IIRECONSTRUCTIVE TRANSPLANTATION OF THE UPPER EXTREMITYHand transplantation was first performed in humans in the late 1990s both in Louisville, Kentucky, and Lyon, France.117 The treating surgeons were able to successfully remove an upper extremity from a brain-dead donor, attach it to an upper extrem-ity amputee, and have the tissue survive. In the subsequent 15 years, many additional centers have achieved technical suc-cess with upper extremity transplantation as well.The technical considerations of hand transplantation have proven to be only the beginning of challenges in bring-ing this treatment option to the general public. Replantation of an amputated limb was first reported by Malt in |
Surgery_Schwartz_12912 | Surgery_Schwartz | of hand transplantation have proven to be only the beginning of challenges in bring-ing this treatment option to the general public. Replantation of an amputated limb was first reported by Malt in 1962.118 In a limb replantation, there is a zone of injury, and cold preser-vation of the amputated part does not begin immediately. In a limb transplant, the harvest can be done as proximally as neces-sary to ensure that only healthy tissue is present on both sides of the repair and to obviate the need for limb shortening, and cold preservation of the amputated part can begin immediately after harvest.A major concern regarding the use of limb transplanta-tion is the immunosuppression medications required to prevent rejection of the transplanted limb. Unlike organ transplantation, which provides a critical organ without which the recipient could not survive or would require chronic mechanical support (e.g., hemodialysis), the absence of one or even multiple limbs does not represent an | Surgery_Schwartz. of hand transplantation have proven to be only the beginning of challenges in bring-ing this treatment option to the general public. Replantation of an amputated limb was first reported by Malt in 1962.118 In a limb replantation, there is a zone of injury, and cold preser-vation of the amputated part does not begin immediately. In a limb transplant, the harvest can be done as proximally as neces-sary to ensure that only healthy tissue is present on both sides of the repair and to obviate the need for limb shortening, and cold preservation of the amputated part can begin immediately after harvest.A major concern regarding the use of limb transplanta-tion is the immunosuppression medications required to prevent rejection of the transplanted limb. Unlike organ transplantation, which provides a critical organ without which the recipient could not survive or would require chronic mechanical support (e.g., hemodialysis), the absence of one or even multiple limbs does not represent an |
Surgery_Schwartz_12913 | Surgery_Schwartz | a critical organ without which the recipient could not survive or would require chronic mechanical support (e.g., hemodialysis), the absence of one or even multiple limbs does not represent an immediate threat to a patient’s survival. Multiple studies have documented the nephrotoxic and other side effects of tacrolimus (FK 506), the principle antirejection agent used in transplant immunomodulation protocols.119,120Due to these concerns, much research has been directed at minimizing the amount of antirejection medication as well as promoting tolerance or even chimerism. Donor bone mar-row transplantation to the limb transplant recipient has been shown to be beneficial toward this purpose and is part of the limb transplant protocol in some centers.121,122 Recent research with donor bone marrow infusions has shown that lower lev-els of immunosuppressive drugs may be possible, as well as fewer immunosuppressive agents.121 Further research is needed in order to determine the efficacy and | Surgery_Schwartz. a critical organ without which the recipient could not survive or would require chronic mechanical support (e.g., hemodialysis), the absence of one or even multiple limbs does not represent an immediate threat to a patient’s survival. Multiple studies have documented the nephrotoxic and other side effects of tacrolimus (FK 506), the principle antirejection agent used in transplant immunomodulation protocols.119,120Due to these concerns, much research has been directed at minimizing the amount of antirejection medication as well as promoting tolerance or even chimerism. Donor bone mar-row transplantation to the limb transplant recipient has been shown to be beneficial toward this purpose and is part of the limb transplant protocol in some centers.121,122 Recent research with donor bone marrow infusions has shown that lower lev-els of immunosuppressive drugs may be possible, as well as fewer immunosuppressive agents.121 Further research is needed in order to determine the efficacy and |
Surgery_Schwartz_12914 | Surgery_Schwartz | infusions has shown that lower lev-els of immunosuppressive drugs may be possible, as well as fewer immunosuppressive agents.121 Further research is needed in order to determine the efficacy and utility of donor bone mar-row transfusions and how they impact transplant recipients in the short and long term.The final challenge in consideration of a patient for limb transplantation is selection of an appropriate candidate. There are multiple patient factors that need to be considered to deter-mine if a patient is an appropriate candidate for hand transplan-tation. These include medical concerns, such as immunologic issues (both antibodies and the presence of occult neoplasms or indolent viruses such as cytomegalovirus), hematologic issues including coagulopathies, and anatomic issues such as quality of skin envelope and amputation level of the bone and neuro-muscular structures. Psychological and social factors must also be considered related to the recipient’s ability to comply with | Surgery_Schwartz. infusions has shown that lower lev-els of immunosuppressive drugs may be possible, as well as fewer immunosuppressive agents.121 Further research is needed in order to determine the efficacy and utility of donor bone mar-row transfusions and how they impact transplant recipients in the short and long term.The final challenge in consideration of a patient for limb transplantation is selection of an appropriate candidate. There are multiple patient factors that need to be considered to deter-mine if a patient is an appropriate candidate for hand transplan-tation. These include medical concerns, such as immunologic issues (both antibodies and the presence of occult neoplasms or indolent viruses such as cytomegalovirus), hematologic issues including coagulopathies, and anatomic issues such as quality of skin envelope and amputation level of the bone and neuro-muscular structures. Psychological and social factors must also be considered related to the recipient’s ability to comply with |
Surgery_Schwartz_12915 | Surgery_Schwartz | as quality of skin envelope and amputation level of the bone and neuro-muscular structures. Psychological and social factors must also be considered related to the recipient’s ability to comply with postoperative medication and therapy protocols as well as to cope with a continuous visible presence of a limb originating from another person.123The promise of upper limb transplantation as a recon-structive technique remains high. Both civilian and military amputees stand to receive a marked functional benefit from this treatment. With the number of transplants performed worldwide ABCFigure 44-32. Syndactyly. A. Hand of a 1-year-old patient with complex syndactyly between the long and ring fingers. Complex syndactyly refers to fingers joined by bone or cartilaginous union, usually in a side-to-side fashion at the distal phalanges. B. Antero-posterior radiograph. C. The syndactyly is divided with interdigitat-ing full-thickness flaps, a dorsal trapezoidal-shaped flap to resurface the | Surgery_Schwartz. as quality of skin envelope and amputation level of the bone and neuro-muscular structures. Psychological and social factors must also be considered related to the recipient’s ability to comply with postoperative medication and therapy protocols as well as to cope with a continuous visible presence of a limb originating from another person.123The promise of upper limb transplantation as a recon-structive technique remains high. Both civilian and military amputees stand to receive a marked functional benefit from this treatment. With the number of transplants performed worldwide ABCFigure 44-32. Syndactyly. A. Hand of a 1-year-old patient with complex syndactyly between the long and ring fingers. Complex syndactyly refers to fingers joined by bone or cartilaginous union, usually in a side-to-side fashion at the distal phalanges. B. Antero-posterior radiograph. C. The syndactyly is divided with interdigitat-ing full-thickness flaps, a dorsal trapezoidal-shaped flap to resurface the |
Surgery_Schwartz_12916 | Surgery_Schwartz | fashion at the distal phalanges. B. Antero-posterior radiograph. C. The syndactyly is divided with interdigitat-ing full-thickness flaps, a dorsal trapezoidal-shaped flap to resurface the floor of the web space, and full-thickness skin grafts. Note the skin grafts on the ulnar and radial sides of the new web space.Brunicardi_Ch44_p1925-p1966.indd 196220/02/19 2:50 PM 1963SURGERY OF THE HAND AND WRISTCHAPTER 44approaching 100 as well as decades of animal research, under-standing of how best to use this technique from functional, patient safety, and cost-effectiveness standpoints continues to grow.REFERENCESEntries highlighted in bright blue are key references. 1. American Society for Surgery of the Hand. The Hand: Examination and Diagnosis. 3rd ed. New York: Churchill Livingstone; 1990:5-13. 2. Moore KL. The Upper Limb. Clinically Oriented Anatomy. Baltimore: Williams & Wilkins; 1992:501-635. 3. Schuind F, Cooney WP, Linscheid RL, An KN, Chao EY. Force and pressure transmission | Surgery_Schwartz. fashion at the distal phalanges. B. Antero-posterior radiograph. C. The syndactyly is divided with interdigitat-ing full-thickness flaps, a dorsal trapezoidal-shaped flap to resurface the floor of the web space, and full-thickness skin grafts. Note the skin grafts on the ulnar and radial sides of the new web space.Brunicardi_Ch44_p1925-p1966.indd 196220/02/19 2:50 PM 1963SURGERY OF THE HAND AND WRISTCHAPTER 44approaching 100 as well as decades of animal research, under-standing of how best to use this technique from functional, patient safety, and cost-effectiveness standpoints continues to grow.REFERENCESEntries highlighted in bright blue are key references. 1. American Society for Surgery of the Hand. The Hand: Examination and Diagnosis. 3rd ed. New York: Churchill Livingstone; 1990:5-13. 2. Moore KL. The Upper Limb. Clinically Oriented Anatomy. Baltimore: Williams & Wilkins; 1992:501-635. 3. Schuind F, Cooney WP, Linscheid RL, An KN, Chao EY. Force and pressure transmission |
Surgery_Schwartz_12917 | Surgery_Schwartz | KL. The Upper Limb. Clinically Oriented Anatomy. Baltimore: Williams & Wilkins; 1992:501-635. 3. Schuind F, Cooney WP, Linscheid RL, An KN, Chao EY. Force and pressure transmission through the normal wrist. A theoretical two-dimensional study in the posteroanterior plane. J Biomech. 1995;28(5):587-601. 4. Gordon JA, Stone L, Gordon L. Surface markers for locating the pulleys and flexor tendon anatomy in the palm and fingers with reference to minimally invasive incisions. J Hand Surg Am. 2012;37:913-918. 5. Dumanian GA, Segalman K, Buehner JW, Koontz CL, Hendrickson MF, Wilgis EF. Analysis of digital pulse-volume recordings with radial and ulnar artery compression. Plast Reconstr Surg. 1998;102:1993-1998. 6. Green DP. General principles. In: Green DP, Hotchkiss RN, Pedersen WC, Wolfe SW, eds. Green’s Operative Hand Sur-gery. 5th ed. Philadelphia: Churchill Livingstone; 2005:3-24. 7. Gilula LA. Carpal injuries: analytic approach and case exer-cises. AJR Am J Roentgenol. | Surgery_Schwartz. KL. The Upper Limb. Clinically Oriented Anatomy. Baltimore: Williams & Wilkins; 1992:501-635. 3. Schuind F, Cooney WP, Linscheid RL, An KN, Chao EY. Force and pressure transmission through the normal wrist. A theoretical two-dimensional study in the posteroanterior plane. J Biomech. 1995;28(5):587-601. 4. Gordon JA, Stone L, Gordon L. Surface markers for locating the pulleys and flexor tendon anatomy in the palm and fingers with reference to minimally invasive incisions. J Hand Surg Am. 2012;37:913-918. 5. Dumanian GA, Segalman K, Buehner JW, Koontz CL, Hendrickson MF, Wilgis EF. Analysis of digital pulse-volume recordings with radial and ulnar artery compression. Plast Reconstr Surg. 1998;102:1993-1998. 6. Green DP. General principles. In: Green DP, Hotchkiss RN, Pedersen WC, Wolfe SW, eds. Green’s Operative Hand Sur-gery. 5th ed. Philadelphia: Churchill Livingstone; 2005:3-24. 7. Gilula LA. Carpal injuries: analytic approach and case exer-cises. AJR Am J Roentgenol. |
Surgery_Schwartz_12918 | Surgery_Schwartz | WC, Wolfe SW, eds. Green’s Operative Hand Sur-gery. 5th ed. Philadelphia: Churchill Livingstone; 2005:3-24. 7. Gilula LA. Carpal injuries: analytic approach and case exer-cises. AJR Am J Roentgenol. 1979;133:503-517. 8. Karl JW, Swart E, Strauch RJ. Diagnosis of occult scaphoid fractures: a cost-effectiveness analysis. J Bone Joint Surg Am. 2015;97(22):1860-1868. 9. Dezfuli B, Taljanovic MS, Melville DM, Krupinski EA, Sheppard JE. Accuracy of high-resolution ultrasonography in the detection of extensor tendon lacerations. Ann Plast Surg. 2016;76(2):187-192. 10. Kretsinger K, Broder KR, Cortese MM, et al. Preventing teta-nus, diphtheria, and pertussis among adults: use of tetanus tox-oid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immuni-zation Practices (ACIP) and recommendation of ACIP, sup-ported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR | Surgery_Schwartz. WC, Wolfe SW, eds. Green’s Operative Hand Sur-gery. 5th ed. Philadelphia: Churchill Livingstone; 2005:3-24. 7. Gilula LA. Carpal injuries: analytic approach and case exer-cises. AJR Am J Roentgenol. 1979;133:503-517. 8. Karl JW, Swart E, Strauch RJ. Diagnosis of occult scaphoid fractures: a cost-effectiveness analysis. J Bone Joint Surg Am. 2015;97(22):1860-1868. 9. Dezfuli B, Taljanovic MS, Melville DM, Krupinski EA, Sheppard JE. Accuracy of high-resolution ultrasonography in the detection of extensor tendon lacerations. Ann Plast Surg. 2016;76(2):187-192. 10. Kretsinger K, Broder KR, Cortese MM, et al. Preventing teta-nus, diphtheria, and pertussis among adults: use of tetanus tox-oid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immuni-zation Practices (ACIP) and recommendation of ACIP, sup-ported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR |
Surgery_Schwartz_12919 | Surgery_Schwartz | on Immuni-zation Practices (ACIP) and recommendation of ACIP, sup-ported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. 2006;55(Rr-17):1-37. 11. Hastings H 2nd, Carroll C 4th. Treatment of closed articu-lar fractures of the metacarpophalangeal and interphalangeal joints. Hand Clin. 1988;4:203-227. 12. Liodaki E, Xing SG, Mailaender P, Stang F. Management of difficult intra-articular fractures or fracture dislocations of the proximal interphalangeal joint. J Hand Surg Eur Vol. 2015;40(1):16-23. 13. Jahss SA. Fractures of the metacarpals: a new method of reduction and immobilization. J Bone Joint Surg. 1938;20(1):178-186. 14. Bond CD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83-a(4):483-488. 15. Mayfield JK, Johnson RP, Kilcoyne RF. The ligaments of the human wrist and their functional significance. Anat Rec. | Surgery_Schwartz. on Immuni-zation Practices (ACIP) and recommendation of ACIP, sup-ported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep. 2006;55(Rr-17):1-37. 11. Hastings H 2nd, Carroll C 4th. Treatment of closed articu-lar fractures of the metacarpophalangeal and interphalangeal joints. Hand Clin. 1988;4:203-227. 12. Liodaki E, Xing SG, Mailaender P, Stang F. Management of difficult intra-articular fractures or fracture dislocations of the proximal interphalangeal joint. J Hand Surg Eur Vol. 2015;40(1):16-23. 13. Jahss SA. Fractures of the metacarpals: a new method of reduction and immobilization. J Bone Joint Surg. 1938;20(1):178-186. 14. Bond CD. Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83-a(4):483-488. 15. Mayfield JK, Johnson RP, Kilcoyne RF. The ligaments of the human wrist and their functional significance. Anat Rec. |
Surgery_Schwartz_12920 | Surgery_Schwartz | nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83-a(4):483-488. 15. Mayfield JK, Johnson RP, Kilcoyne RF. The ligaments of the human wrist and their functional significance. Anat Rec. 1976;186(3):417-428. 16. Apostolides JG, Lifchez SD, Christy MR. Complex and rare fracture patterns in perilunate dislocations. Hand (N Y). 2011;6(3):287-294. 17. Kleinert HE, Kutz JE, Atasoy E, Stormo A. Primary repair of flexor tendons. Orthop Clin North Am. 1973;4(4): 865-876. This key manuscript changed the “axiom” and established that zone two flexor tendon injuries could be immediately repaired primarly. 18. Vinycomb TI, Sahhar LJ. Comparison of local anesthetics for digital nerve blocks: a systematic review. J Hand Surg Am. 2010;39(4):744-751.e5. 19. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. | Surgery_Schwartz. nondisplaced scaphoid fractures. J Bone Joint Surg Am. 2001;83-a(4):483-488. 15. Mayfield JK, Johnson RP, Kilcoyne RF. The ligaments of the human wrist and their functional significance. Anat Rec. 1976;186(3):417-428. 16. Apostolides JG, Lifchez SD, Christy MR. Complex and rare fracture patterns in perilunate dislocations. Hand (N Y). 2011;6(3):287-294. 17. Kleinert HE, Kutz JE, Atasoy E, Stormo A. Primary repair of flexor tendons. Orthop Clin North Am. 1973;4(4): 865-876. This key manuscript changed the “axiom” and established that zone two flexor tendon injuries could be immediately repaired primarly. 18. Vinycomb TI, Sahhar LJ. Comparison of local anesthetics for digital nerve blocks: a systematic review. J Hand Surg Am. 2010;39(4):744-751.e5. 19. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. |
Surgery_Schwartz_12921 | Surgery_Schwartz | P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005;30:1061-1067. This large case series supports that the use of lidocaine with epinephrine is safe to use in the hand. 20. Yousif NJ, Grunert BK, Forte RA, Matloub HS, Sanger JR. A comparison of upper arm and forearm tourniquet tolerance. J Hand Surg Br. 1993;18:639-641. 21. Lee HJ, Cho YJ, Gong HS, Rhee SH, Park HS, Baek GH. The effect of buffered lidocaine in local anesthesia: a pro-spective, randomized, double-blind study. J Hand Surg Am. 2013;38(5):971-975. 22. Best CA, Best AA, Best TJ, Hamilton DA. Buffered lidocaine and bupivacaine mixture—the ideal local anesthetic solution? Plast Surg (Oakv). 2015;23(2):87-90. 23. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr | Surgery_Schwartz. P, Sparkes G, Denkler K, Chang P. A multicenter prospective study of 3110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am. 2005;30:1061-1067. This large case series supports that the use of lidocaine with epinephrine is safe to use in the hand. 20. Yousif NJ, Grunert BK, Forte RA, Matloub HS, Sanger JR. A comparison of upper arm and forearm tourniquet tolerance. J Hand Surg Br. 1993;18:639-641. 21. Lee HJ, Cho YJ, Gong HS, Rhee SH, Park HS, Baek GH. The effect of buffered lidocaine in local anesthesia: a pro-spective, randomized, double-blind study. J Hand Surg Am. 2013;38(5):971-975. 22. Best CA, Best AA, Best TJ, Hamilton DA. Buffered lidocaine and bupivacaine mixture—the ideal local anesthetic solution? Plast Surg (Oakv). 2015;23(2):87-90. 23. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr |
Surgery_Schwartz_12922 | Surgery_Schwartz | Surg (Oakv). 2015;23(2):87-90. 23. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg. 2010; 126(3):941-945. 24. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (N Y). 2013;8(1):47-53. 25. Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012;37(4):645-650. 26. Stanek JJ, Renslow MA, Kalliainen LK. The effect of an educational program on opioid prescription patterns in hand surgery: a quality improvement program. J Hand Surg Am. 2015;40(2):341-346. 27. Komatsu S, Tamai S. Successful replantation of a com-pletely cut-off thumb: case report. Plast Reconstr Surg. 1968;42:374-377. 28. Lifchez SD, Marchant-Hanson J, Matloub HS, Sanger JR, Dzwierzynski WW, Nguyen HH. Functional improvement with | Surgery_Schwartz. Surg (Oakv). 2015;23(2):87-90. 23. Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg. 2010; 126(3):941-945. 24. Davison PG, Cobb T, Lalonde DH. The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand (N Y). 2013;8(1):47-53. 25. Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012;37(4):645-650. 26. Stanek JJ, Renslow MA, Kalliainen LK. The effect of an educational program on opioid prescription patterns in hand surgery: a quality improvement program. J Hand Surg Am. 2015;40(2):341-346. 27. Komatsu S, Tamai S. Successful replantation of a com-pletely cut-off thumb: case report. Plast Reconstr Surg. 1968;42:374-377. 28. Lifchez SD, Marchant-Hanson J, Matloub HS, Sanger JR, Dzwierzynski WW, Nguyen HH. Functional improvement with |
Surgery_Schwartz_12923 | Surgery_Schwartz | of a com-pletely cut-off thumb: case report. Plast Reconstr Surg. 1968;42:374-377. 28. Lifchez SD, Marchant-Hanson J, Matloub HS, Sanger JR, Dzwierzynski WW, Nguyen HH. Functional improvement with digital prosthesis use after multiple digit amputations. J Hand Surg Am. 2005;30:790-794. 29. Weichman KE, Wilson SC, Samra F, Reavey P, Sharma S, Haddock NT. Treatment and outcomes of fingertip injuries at a large metropolitan public hospital. Plast Reconstr Surg. 2013;131(1):107-112. 30. Bickel KD, Dosanjh A. Fingertip reconstruction. J Hand Surg Am. 2008;33(8):1417-1419. 31. Moberg E. The treatment of mutilating injuries of the upper limb. Surg Clin North Am. 1964;44:1107-1113. 32. Melone CP, Jr, Beasley RW, Carstens JH, Jr. The thenar flap—an analysis of its use in 150 cases. J Hand Surg Am. 1982;7(3):291-297. 33. Johnson RK, Iverson RE. Cross-finger pedicle flaps in the hand. J Bone Joint Surg Am. 1971;53(5):913-919. 34. Cannon TA. High-pressure injection injuries of the hand. Orthop | Surgery_Schwartz. of a com-pletely cut-off thumb: case report. Plast Reconstr Surg. 1968;42:374-377. 28. Lifchez SD, Marchant-Hanson J, Matloub HS, Sanger JR, Dzwierzynski WW, Nguyen HH. Functional improvement with digital prosthesis use after multiple digit amputations. J Hand Surg Am. 2005;30:790-794. 29. Weichman KE, Wilson SC, Samra F, Reavey P, Sharma S, Haddock NT. Treatment and outcomes of fingertip injuries at a large metropolitan public hospital. Plast Reconstr Surg. 2013;131(1):107-112. 30. Bickel KD, Dosanjh A. Fingertip reconstruction. J Hand Surg Am. 2008;33(8):1417-1419. 31. Moberg E. The treatment of mutilating injuries of the upper limb. Surg Clin North Am. 1964;44:1107-1113. 32. Melone CP, Jr, Beasley RW, Carstens JH, Jr. The thenar flap—an analysis of its use in 150 cases. J Hand Surg Am. 1982;7(3):291-297. 33. Johnson RK, Iverson RE. Cross-finger pedicle flaps in the hand. J Bone Joint Surg Am. 1971;53(5):913-919. 34. Cannon TA. High-pressure injection injuries of the hand. Orthop |
Surgery_Schwartz_12924 | Surgery_Schwartz | 1982;7(3):291-297. 33. Johnson RK, Iverson RE. Cross-finger pedicle flaps in the hand. J Bone Joint Surg Am. 1971;53(5):913-919. 34. Cannon TA. High-pressure injection injuries of the hand. Orthop Clin North Am. 2016;47(3):617-624. 35. Bekler H, Gokce A, Beyzadeoglu T, Parmaksizoglu F. The sur-gical treatment and outcomes of high-pressure injection inju-ries of the hand. J Hand Surg Eur Vol. 2007;32(4):394-399. 36. Kalyani BS et al. Compartment syndrome of the forearm: a systematic review. J Hand Surg Am. 2011;36(3):535-543. 37. Staudt JM, Smeulders MJ, van der Horst CM. Normal com-partment pressures of the lower leg in children. J Bone Joint Surg Br. 2008;90(2):215-219. 38. Al-Qattan MM, Abou Al-Shaar H, Al Mugaren FM. Non-union without avascular necrosis of finger phalangeal neck Brunicardi_Ch44_p1925-p1966.indd 196320/02/19 2:50 PM 1964SPECIFIC CONSIDERATIONSPART IIfractures in children: report of 4 cases. J Hand Surg Am. 2014;39(8):1529-1534. 39. Munk B, Larsen CF. Bone | Surgery_Schwartz. 1982;7(3):291-297. 33. Johnson RK, Iverson RE. Cross-finger pedicle flaps in the hand. J Bone Joint Surg Am. 1971;53(5):913-919. 34. Cannon TA. High-pressure injection injuries of the hand. Orthop Clin North Am. 2016;47(3):617-624. 35. Bekler H, Gokce A, Beyzadeoglu T, Parmaksizoglu F. The sur-gical treatment and outcomes of high-pressure injection inju-ries of the hand. J Hand Surg Eur Vol. 2007;32(4):394-399. 36. Kalyani BS et al. Compartment syndrome of the forearm: a systematic review. J Hand Surg Am. 2011;36(3):535-543. 37. Staudt JM, Smeulders MJ, van der Horst CM. Normal com-partment pressures of the lower leg in children. J Bone Joint Surg Br. 2008;90(2):215-219. 38. Al-Qattan MM, Abou Al-Shaar H, Al Mugaren FM. Non-union without avascular necrosis of finger phalangeal neck Brunicardi_Ch44_p1925-p1966.indd 196320/02/19 2:50 PM 1964SPECIFIC CONSIDERATIONSPART IIfractures in children: report of 4 cases. J Hand Surg Am. 2014;39(8):1529-1534. 39. Munk B, Larsen CF. Bone |
Surgery_Schwartz_12925 | Surgery_Schwartz | Brunicardi_Ch44_p1925-p1966.indd 196320/02/19 2:50 PM 1964SPECIFIC CONSIDERATIONSPART IIfractures in children: report of 4 cases. J Hand Surg Am. 2014;39(8):1529-1534. 39. Munk B, Larsen CF. Bone grafting the scaphoid nonunion: a systematic review of 147 publications including 5,246 cases of scaphoid nonunion. Acta Orthop Scand. 2004;75(5):618-629. 40. Curtis RM. Capsulectomy of the interphalangeal joints of the fingers. J Bone Joint Surg Am. 1954;36-a(6):1219-1232. 41. Brogan DM, Kakar S. Management of neuromas of the upper extremity. Hand Clin. 2013;29(3):409-420. 42. Zimmerman RM, Astifidis RP, Katz RD. Modalities for complex regional pain syndrome. J Hand Surg Am. 2015;40(7):1469-1472. 43. Schurmann M, Zaspel J, Löhr P, et al. Imaging in early post-traumatic complex regional pain syndrome: a comparison of diagnostic methods. Clin J Pain. 2007;23(5):449-457. 44. Mackinnon SE. Pathophysiology of nerve compression. Hand Clin. 2002;18(2):231-241. 45. US Department of Health and | Surgery_Schwartz. Brunicardi_Ch44_p1925-p1966.indd 196320/02/19 2:50 PM 1964SPECIFIC CONSIDERATIONSPART IIfractures in children: report of 4 cases. J Hand Surg Am. 2014;39(8):1529-1534. 39. Munk B, Larsen CF. Bone grafting the scaphoid nonunion: a systematic review of 147 publications including 5,246 cases of scaphoid nonunion. Acta Orthop Scand. 2004;75(5):618-629. 40. Curtis RM. Capsulectomy of the interphalangeal joints of the fingers. J Bone Joint Surg Am. 1954;36-a(6):1219-1232. 41. Brogan DM, Kakar S. Management of neuromas of the upper extremity. Hand Clin. 2013;29(3):409-420. 42. Zimmerman RM, Astifidis RP, Katz RD. Modalities for complex regional pain syndrome. J Hand Surg Am. 2015;40(7):1469-1472. 43. Schurmann M, Zaspel J, Löhr P, et al. Imaging in early post-traumatic complex regional pain syndrome: a comparison of diagnostic methods. Clin J Pain. 2007;23(5):449-457. 44. Mackinnon SE. Pathophysiology of nerve compression. Hand Clin. 2002;18(2):231-241. 45. US Department of Health and |
Surgery_Schwartz_12926 | Surgery_Schwartz | syndrome: a comparison of diagnostic methods. Clin J Pain. 2007;23(5):449-457. 44. Mackinnon SE. Pathophysiology of nerve compression. Hand Clin. 2002;18(2):231-241. 45. US Department of Health and Human Services. Hand/wrist musculoskeletal disorders (carpal tunnel syndrome, hand/wrist tendonitis, and hand-arm vibration syndrome): evidence for work-relatedness. Available at: https://www.cdc.gov/niosh/docs/97-141/pdfs/97-141.pdf. Accessed August 16, 2018. 46. American Academy of Orthopedic Surgeons. Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline. Available at: https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/CTS%20CPG_2.29.16.pdf. Accessed August 16, 2018. 47. Lifchez SD, Means KR, Jr, Dunn RE, Williams EH, Dellon AL. Intraand inter-examiner variability in performing Tinel’s test. J Hand Surg Am. 2010;35(2):212-216. 48. Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L. Verification of the pressure | Surgery_Schwartz. syndrome: a comparison of diagnostic methods. Clin J Pain. 2007;23(5):449-457. 44. Mackinnon SE. Pathophysiology of nerve compression. Hand Clin. 2002;18(2):231-241. 45. US Department of Health and Human Services. Hand/wrist musculoskeletal disorders (carpal tunnel syndrome, hand/wrist tendonitis, and hand-arm vibration syndrome): evidence for work-relatedness. Available at: https://www.cdc.gov/niosh/docs/97-141/pdfs/97-141.pdf. Accessed August 16, 2018. 46. American Academy of Orthopedic Surgeons. Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline. Available at: https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/CTS%20CPG_2.29.16.pdf. Accessed August 16, 2018. 47. Lifchez SD, Means KR, Jr, Dunn RE, Williams EH, Dellon AL. Intraand inter-examiner variability in performing Tinel’s test. J Hand Surg Am. 2010;35(2):212-216. 48. Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L. Verification of the pressure |
Surgery_Schwartz_12927 | Surgery_Schwartz | AL. Intraand inter-examiner variability in performing Tinel’s test. J Hand Surg Am. 2010;35(2):212-216. 48. Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L. Verification of the pressure provocative test in carpal tunnel syndrome. Ann Plast Surg. 1992;29(1):8-11. 49. Marshall S, Tardif G, Ashworth N. Local corticosteroid injec-tion for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007(2):Cd001554. 50. Trumble TE, Diao E, Abrams RA, Gilbert-Anderson MM. Single-portal endoscopic carpal tunnel release compared with open release : a prospective, randomized trial. J Bone Joint Surg Am. 2002;84-a(7):1107-1115. Carpal tunnel release is one of the most common procedures performed by hand sur-geons. This study by Trumble highlights that although patients undergoing endoscopic carpal tunnel release have less pain in the immediate postoperative period, clinical outcomes after 3 months show no difference compared to traditional open approaches. 51. Mackinnon SE, Novak CB. | Surgery_Schwartz. AL. Intraand inter-examiner variability in performing Tinel’s test. J Hand Surg Am. 2010;35(2):212-216. 48. Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L. Verification of the pressure provocative test in carpal tunnel syndrome. Ann Plast Surg. 1992;29(1):8-11. 49. Marshall S, Tardif G, Ashworth N. Local corticosteroid injec-tion for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007(2):Cd001554. 50. Trumble TE, Diao E, Abrams RA, Gilbert-Anderson MM. Single-portal endoscopic carpal tunnel release compared with open release : a prospective, randomized trial. J Bone Joint Surg Am. 2002;84-a(7):1107-1115. Carpal tunnel release is one of the most common procedures performed by hand sur-geons. This study by Trumble highlights that although patients undergoing endoscopic carpal tunnel release have less pain in the immediate postoperative period, clinical outcomes after 3 months show no difference compared to traditional open approaches. 51. Mackinnon SE, Novak CB. |
Surgery_Schwartz_12928 | Surgery_Schwartz | carpal tunnel release have less pain in the immediate postoperative period, clinical outcomes after 3 months show no difference compared to traditional open approaches. 51. Mackinnon SE, Novak CB. Compression neuropathies. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; 2016:921-958. This chapter does well to explain the mechanism, pathophysiology, and treatment for compression neuropathies in the upper extremity. 52. Ochi K, Horiuchi Y, Tanabe A, Morita K, Takeda K, Ninomiya K. Comparison of shoulder internal rotation test with the elbow flexion test in the diagnosis of cubital tunnel syndrome. J Hand Surg Am. 2011;36(5):782-787. 53. Goldfarb CA, Sutter MM, Martens EJ, Manske PR. Incidence of re-operation and subjective outcome following in situ decompression of the ulnar nerve at the cubital tunnel. J Hand Surg Eur Vol. 2009;34:379-383. 54. Kocak E, Carruthers KH, Kobus RJ. Distal interphalangeal joint arthrodesis | Surgery_Schwartz. carpal tunnel release have less pain in the immediate postoperative period, clinical outcomes after 3 months show no difference compared to traditional open approaches. 51. Mackinnon SE, Novak CB. Compression neuropathies. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; 2016:921-958. This chapter does well to explain the mechanism, pathophysiology, and treatment for compression neuropathies in the upper extremity. 52. Ochi K, Horiuchi Y, Tanabe A, Morita K, Takeda K, Ninomiya K. Comparison of shoulder internal rotation test with the elbow flexion test in the diagnosis of cubital tunnel syndrome. J Hand Surg Am. 2011;36(5):782-787. 53. Goldfarb CA, Sutter MM, Martens EJ, Manske PR. Incidence of re-operation and subjective outcome following in situ decompression of the ulnar nerve at the cubital tunnel. J Hand Surg Eur Vol. 2009;34:379-383. 54. Kocak E, Carruthers KH, Kobus RJ. Distal interphalangeal joint arthrodesis |
Surgery_Schwartz_12929 | Surgery_Schwartz | outcome following in situ decompression of the ulnar nerve at the cubital tunnel. J Hand Surg Eur Vol. 2009;34:379-383. 54. Kocak E, Carruthers KH, Kobus RJ. Distal interphalangeal joint arthrodesis with the Herbert headless compression screw: outcomes and complications in 64 consecutively treated joints. Hand (N Y). 2011;6(1):56-59. 55. Swanson AB. Implant resection arthroplasty of the proximal interphalangeal joint. Orthop Clin North Am. 1973;4:1007-1029. 56. Adkinson JM, Chung KC. Advances in small joint arthroplasty of the hand. Plast Reconstr Surg. 2014;134(6):1260-1268. 57. Naram A, Lyons K, Rothkopf DM, et al. Increased complica-tions in trapeziectomy with ligament reconstruction and ten-don interposition compared with trapeziectomy alone. Hand (N Y). 2016;11(1):78-82. 58. Gray KV, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5-year follow-up evaluation. J Hand Surg Am. 2007;32(1):23-29. 59. Kenniston JA, Bozentka DJ. Treatment | Surgery_Schwartz. outcome following in situ decompression of the ulnar nerve at the cubital tunnel. J Hand Surg Eur Vol. 2009;34:379-383. 54. Kocak E, Carruthers KH, Kobus RJ. Distal interphalangeal joint arthrodesis with the Herbert headless compression screw: outcomes and complications in 64 consecutively treated joints. Hand (N Y). 2011;6(1):56-59. 55. Swanson AB. Implant resection arthroplasty of the proximal interphalangeal joint. Orthop Clin North Am. 1973;4:1007-1029. 56. Adkinson JM, Chung KC. Advances in small joint arthroplasty of the hand. Plast Reconstr Surg. 2014;134(6):1260-1268. 57. Naram A, Lyons K, Rothkopf DM, et al. Increased complica-tions in trapeziectomy with ligament reconstruction and ten-don interposition compared with trapeziectomy alone. Hand (N Y). 2016;11(1):78-82. 58. Gray KV, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5-year follow-up evaluation. J Hand Surg Am. 2007;32(1):23-29. 59. Kenniston JA, Bozentka DJ. Treatment |
Surgery_Schwartz_12930 | Surgery_Schwartz | Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5-year follow-up evaluation. J Hand Surg Am. 2007;32(1):23-29. 59. Kenniston JA, Bozentka DJ. Treatment of advanced carpo-metacarpal joint disease: arthrodesis. Hand Clin. 2008;24(3): 285-294, vi-vii. 60. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3):358-365. 61. Wall LB, Didonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg Am. 2013;38(8):1498-1504. 62. Goldfarb CA, Stern PJ, Kiefhaber TR. Palmar midcarpal instability: the results of treatment with 4-corner arthrodesis. J Hand Surg Am. 2004;29(2):258-263. 63. Chung KC, Pushman AG. Current concepts in the man-agement of the rheumatoid hand. J Hand Surg Am. 2011;36(4):736-747; quiz 747. Surgical treatment for rheu-matoid arthritis of the hand has decreased due to the advances in medical management. This article | Surgery_Schwartz. Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5-year follow-up evaluation. J Hand Surg Am. 2007;32(1):23-29. 59. Kenniston JA, Bozentka DJ. Treatment of advanced carpo-metacarpal joint disease: arthrodesis. Hand Clin. 2008;24(3): 285-294, vi-vii. 60. Watson HK, Ballet FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg Am. 1984;9(3):358-365. 61. Wall LB, Didonna ML, Kiefhaber TR, Stern PJ. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg Am. 2013;38(8):1498-1504. 62. Goldfarb CA, Stern PJ, Kiefhaber TR. Palmar midcarpal instability: the results of treatment with 4-corner arthrodesis. J Hand Surg Am. 2004;29(2):258-263. 63. Chung KC, Pushman AG. Current concepts in the man-agement of the rheumatoid hand. J Hand Surg Am. 2011;36(4):736-747; quiz 747. Surgical treatment for rheu-matoid arthritis of the hand has decreased due to the advances in medical management. This article |
Surgery_Schwartz_12931 | Surgery_Schwartz | of the rheumatoid hand. J Hand Surg Am. 2011;36(4):736-747; quiz 747. Surgical treatment for rheu-matoid arthritis of the hand has decreased due to the advances in medical management. This article serves as thorough review for hand surgeons on the treatment of rheumatoid hand. 64. Swanson AB. Silicone rubber implants for replacement of arthritis or destroyed joints in the hand. Surg Clin North Am. 1968;48(5):1113-1127. 65. Fujita S, Masada K, Takeuchi E, Yasuda M, Komatsubara Y, Hashimoto H. Modified Sauve-Kapandji procedure for disorders of the distal radioulnar joint in patients with rheu-matoid arthritis. Surgical technique. J Bone Joint Surg Am. 2006;88(Suppl 1 Pt 1):24-28. 66. Elliot D, Ragoowansi R. Dupuytren’s disease secondary to acute injury, infection or operation distal to the elbow in the ipsilateral upper limb—a historical review. J Hand Surg Br. 2005;30(2):148-156. 67. Eaton C. Dupuytren disease. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative | Surgery_Schwartz. of the rheumatoid hand. J Hand Surg Am. 2011;36(4):736-747; quiz 747. Surgical treatment for rheu-matoid arthritis of the hand has decreased due to the advances in medical management. This article serves as thorough review for hand surgeons on the treatment of rheumatoid hand. 64. Swanson AB. Silicone rubber implants for replacement of arthritis or destroyed joints in the hand. Surg Clin North Am. 1968;48(5):1113-1127. 65. Fujita S, Masada K, Takeuchi E, Yasuda M, Komatsubara Y, Hashimoto H. Modified Sauve-Kapandji procedure for disorders of the distal radioulnar joint in patients with rheu-matoid arthritis. Surgical technique. J Bone Joint Surg Am. 2006;88(Suppl 1 Pt 1):24-28. 66. Elliot D, Ragoowansi R. Dupuytren’s disease secondary to acute injury, infection or operation distal to the elbow in the ipsilateral upper limb—a historical review. J Hand Surg Br. 2005;30(2):148-156. 67. Eaton C. Dupuytren disease. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative |
Surgery_Schwartz_12932 | Surgery_Schwartz | the elbow in the ipsilateral upper limb—a historical review. J Hand Surg Br. 2005;30(2):148-156. 67. Eaton C. Dupuytren disease. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; 2016. 68. Murphy A, Lalonde DH, Eaton C, et al. Minimally inva-sive options in Dupuytren’s contracture: aponeurotomy, enzymes, stretching, and fat grafting. Plast Reconstr Surg. 2014;134(5):822e-829e. 69. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fas-ciectomy. Plast Reconstr Surg. 2012;129:469-477. Although percutaneous needle fasciotomy is less invasive than limited fasciectomy, this study showed that fasciectomy provided more durable and lasting results. 70. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable colla-genase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. | Surgery_Schwartz. the elbow in the ipsilateral upper limb—a historical review. J Hand Surg Br. 2005;30(2):148-156. 67. Eaton C. Dupuytren disease. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; 2016. 68. Murphy A, Lalonde DH, Eaton C, et al. Minimally inva-sive options in Dupuytren’s contracture: aponeurotomy, enzymes, stretching, and fat grafting. Plast Reconstr Surg. 2014;134(5):822e-829e. 69. van Rijssen AL, ter Linden H, Werker PM. Five-year results of a randomized clinical trial on treatment in Dupuytren’s disease: percutaneous needle fasciotomy versus limited fas-ciectomy. Plast Reconstr Surg. 2012;129:469-477. Although percutaneous needle fasciotomy is less invasive than limited fasciectomy, this study showed that fasciectomy provided more durable and lasting results. 70. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable colla-genase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. |
Surgery_Schwartz_12933 | Surgery_Schwartz | that fasciectomy provided more durable and lasting results. 70. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable colla-genase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361:968-979. 71. Saar JD, Grothaus PC. Dupuytren’s disease: an overview. Plast Reconstr Surg. 2000;106:125-134. 72. Crean SM, Gerber RA, Le Graverand MP, Boyd DM, Cappelleri JC. The efficacy and safety of fasciectomy and fas-ciotomy for Dupuytren’s contracture in European patients: a structured review of published studies. J Hand Surg Eur Vol. 2011;36:396-407. 73. McDonald LS, Bavaro MF, Hofmeister EP, Kroonen LT. Hand infections. J Hand Surg Am. 2011;36(8):1403-1412.Brunicardi_Ch44_p1925-p1966.indd 196420/02/19 2:50 PM 1965SURGERY OF THE HAND AND WRISTCHAPTER 44 74. Honda H, McDonald JR. Current recommendations in the management of osteomyelitis of the hand and wrist. J Hand Surg Am. 2009;34(6):1135-1136. 75. Murray PM. Septic arthritis of the hand and wrist. Hand Clin. | Surgery_Schwartz. that fasciectomy provided more durable and lasting results. 70. Hurst LC, Badalamente MA, Hentz VR, et al. Injectable colla-genase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361:968-979. 71. Saar JD, Grothaus PC. Dupuytren’s disease: an overview. Plast Reconstr Surg. 2000;106:125-134. 72. Crean SM, Gerber RA, Le Graverand MP, Boyd DM, Cappelleri JC. The efficacy and safety of fasciectomy and fas-ciotomy for Dupuytren’s contracture in European patients: a structured review of published studies. J Hand Surg Eur Vol. 2011;36:396-407. 73. McDonald LS, Bavaro MF, Hofmeister EP, Kroonen LT. Hand infections. J Hand Surg Am. 2011;36(8):1403-1412.Brunicardi_Ch44_p1925-p1966.indd 196420/02/19 2:50 PM 1965SURGERY OF THE HAND AND WRISTCHAPTER 44 74. Honda H, McDonald JR. Current recommendations in the management of osteomyelitis of the hand and wrist. J Hand Surg Am. 2009;34(6):1135-1136. 75. Murray PM. Septic arthritis of the hand and wrist. Hand Clin. |
Surgery_Schwartz_12934 | Surgery_Schwartz | McDonald JR. Current recommendations in the management of osteomyelitis of the hand and wrist. J Hand Surg Am. 2009;34(6):1135-1136. 75. Murray PM. Septic arthritis of the hand and wrist. Hand Clin. 1998;14(4):579-587, viii. 76. Boles SD, Schmidt CC. Pyogenic flexor tenosynovitis. Hand Clin. 1998;14(4):567-578. 77. Kanavel AB. The treatment of acute suppurative tenosynovi-tis—discussion of technique. In: Infections of the Hand; A Guide to the Surgical Treatment of Acute and Chronic Sup-purative Processes in the Fingers, Hand, and Forearm. 5th ed. Philadelphia: Lea and Febiger; 1925:985. 78. Giladi AM, Malay S, Chung KC. A systematic review of the management of acute pyogenic flexor tenosynovitis. J Hand Surg Eur Vol. 2015;40(7):720-728. 79. Michon J. Phlegmon of the tendon sheaths (in French). Ann Chir. 1974;28(4):277-280. 80. Athanasian E. Bone and soft tissue tumors. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; | Surgery_Schwartz. McDonald JR. Current recommendations in the management of osteomyelitis of the hand and wrist. J Hand Surg Am. 2009;34(6):1135-1136. 75. Murray PM. Septic arthritis of the hand and wrist. Hand Clin. 1998;14(4):579-587, viii. 76. Boles SD, Schmidt CC. Pyogenic flexor tenosynovitis. Hand Clin. 1998;14(4):567-578. 77. Kanavel AB. The treatment of acute suppurative tenosynovi-tis—discussion of technique. In: Infections of the Hand; A Guide to the Surgical Treatment of Acute and Chronic Sup-purative Processes in the Fingers, Hand, and Forearm. 5th ed. Philadelphia: Lea and Febiger; 1925:985. 78. Giladi AM, Malay S, Chung KC. A systematic review of the management of acute pyogenic flexor tenosynovitis. J Hand Surg Eur Vol. 2015;40(7):720-728. 79. Michon J. Phlegmon of the tendon sheaths (in French). Ann Chir. 1974;28(4):277-280. 80. Athanasian E. Bone and soft tissue tumors. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; |
Surgery_Schwartz_12935 | Surgery_Schwartz | French). Ann Chir. 1974;28(4):277-280. 80. Athanasian E. Bone and soft tissue tumors. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; 2016. 81. Head L, Gencarelli JR, Allen M. Wrist ganglion treatment: systematic review and meta-analysis. J Hand Surg Am. 2015;40(3):546-553.e8. 82. Lanzinger WD, Bindra R. Giant cell tumor of the tendon sheath. J Hand Surg Am. 2013;38(1):154-157; quiz 157. 83. Phalen GS. Neurilemomas of the forearm and hand. Clin Orthop. 1976;114:219-222. 84. Lekanne Deprez RH, Bianchi AB, Groen NA, et al. Fre-quent NF2 gene transcript mutations in sporadic menin-giomas and vestibular schwannomas. Am J Hum Genet. 1994;54:1022-1029. 85. TerKonda SP, Perdikis G. Non-melanotic skin tumors of the upper extremity. Hand Clin. 2004;20:293-301. 86. Webber T, Wolf JM. Squamous cell carcinoma of the hand in solid organ transplant patients. J Hand Surg Am. 2014;39(3):567-570. 87. English C, Hammert WC. Cutaneous | Surgery_Schwartz. French). Ann Chir. 1974;28(4):277-280. 80. Athanasian E. Bone and soft tissue tumors. In: Wolfe SW, Hotchkiss RN, Kozin SH, Cohen MS, eds. Green’s Operative Hand Surgery. 7th ed. Amsterdam: Elsevier; 2016. 81. Head L, Gencarelli JR, Allen M. Wrist ganglion treatment: systematic review and meta-analysis. J Hand Surg Am. 2015;40(3):546-553.e8. 82. Lanzinger WD, Bindra R. Giant cell tumor of the tendon sheath. J Hand Surg Am. 2013;38(1):154-157; quiz 157. 83. Phalen GS. Neurilemomas of the forearm and hand. Clin Orthop. 1976;114:219-222. 84. Lekanne Deprez RH, Bianchi AB, Groen NA, et al. Fre-quent NF2 gene transcript mutations in sporadic menin-giomas and vestibular schwannomas. Am J Hum Genet. 1994;54:1022-1029. 85. TerKonda SP, Perdikis G. Non-melanotic skin tumors of the upper extremity. Hand Clin. 2004;20:293-301. 86. Webber T, Wolf JM. Squamous cell carcinoma of the hand in solid organ transplant patients. J Hand Surg Am. 2014;39(3):567-570. 87. English C, Hammert WC. Cutaneous |
Surgery_Schwartz_12936 | Surgery_Schwartz | Hand Clin. 2004;20:293-301. 86. Webber T, Wolf JM. Squamous cell carcinoma of the hand in solid organ transplant patients. J Hand Surg Am. 2014;39(3):567-570. 87. English C, Hammert WC. Cutaneous malignancies of the upper extremity. J Hand Surg Am. 2012;37(2):367-377. 88. Coit DG, Thompson JA, Andtbacka R, et al. Melanoma, version 2.2016. J Natl Compr Canc Netw. 2016;14(4): 450-473. 89. Dummer RA, Hauschild A, Lindenblatt N, et al. Cutane-ous malignant melanoma: ESMO clinical recommenda-tions for diagnosis, treatment and follow-up. Ann Oncol. 2009;20(Suppl 4):129-131. 90. Cochran AM. Subungual melanoma: a review of current treat-ment. Plast Reconstr Surg. 2014;134(2):259-273. 91. Mahajan A. The contemporary role of the use of radiation therapy in the management of sarcoma. Surg Oncol Clin N Am. 2000;9(3):503-524, ix. 92. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am. | Surgery_Schwartz. Hand Clin. 2004;20:293-301. 86. Webber T, Wolf JM. Squamous cell carcinoma of the hand in solid organ transplant patients. J Hand Surg Am. 2014;39(3):567-570. 87. English C, Hammert WC. Cutaneous malignancies of the upper extremity. J Hand Surg Am. 2012;37(2):367-377. 88. Coit DG, Thompson JA, Andtbacka R, et al. Melanoma, version 2.2016. J Natl Compr Canc Netw. 2016;14(4): 450-473. 89. Dummer RA, Hauschild A, Lindenblatt N, et al. Cutane-ous malignant melanoma: ESMO clinical recommenda-tions for diagnosis, treatment and follow-up. Ann Oncol. 2009;20(Suppl 4):129-131. 90. Cochran AM. Subungual melanoma: a review of current treat-ment. Plast Reconstr Surg. 2014;134(2):259-273. 91. Mahajan A. The contemporary role of the use of radiation therapy in the management of sarcoma. Surg Oncol Clin N Am. 2000;9(3):503-524, ix. 92. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am. |
Surgery_Schwartz_12937 | Surgery_Schwartz | of sarcoma. Surg Oncol Clin N Am. 2000;9(3):503-524, ix. 92. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am. 1996;78(5):656-663. 93. Murray PM. Soft tissue sarcoma of the upper extremity. Hand Clin. 2004;20(3):325-333, vii. The subject of soft tissue sarcomas is very broad and specific. This article by Murray provides a concise and accurate summary of soft tissue sarco-mas of the upper extremity. 94. Unni KK, Dahlin DC. Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases. 5th ed. Philadelphia: Lippincott-Raven; 1996. 95. Henderson M, Neumeister MW, Bueno RA, Jr. Hand tumors: II. Benign and malignant bone tumors of the hand. Plast Reconstr Surg. 2014;133(6):814e-821e. 96. Marcuzzi A, Acciaro AL, Landi A. Osteoid osteoma of the hand and wrist. J Hand Surg Br. 2002;27(5):440-443. 97. Maloney WJ, Vaughan LM, Jones HH, Ross J, Nagel DA. Benign metastasizing giant-cell tumor of bone. Report | Surgery_Schwartz. of sarcoma. Surg Oncol Clin N Am. 2000;9(3):503-524, ix. 92. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am. 1996;78(5):656-663. 93. Murray PM. Soft tissue sarcoma of the upper extremity. Hand Clin. 2004;20(3):325-333, vii. The subject of soft tissue sarcomas is very broad and specific. This article by Murray provides a concise and accurate summary of soft tissue sarco-mas of the upper extremity. 94. Unni KK, Dahlin DC. Dahlin’s Bone Tumors: General Aspects and Data on 11,087 Cases. 5th ed. Philadelphia: Lippincott-Raven; 1996. 95. Henderson M, Neumeister MW, Bueno RA, Jr. Hand tumors: II. Benign and malignant bone tumors of the hand. Plast Reconstr Surg. 2014;133(6):814e-821e. 96. Marcuzzi A, Acciaro AL, Landi A. Osteoid osteoma of the hand and wrist. J Hand Surg Br. 2002;27(5):440-443. 97. Maloney WJ, Vaughan LM, Jones HH, Ross J, Nagel DA. Benign metastasizing giant-cell tumor of bone. Report |
Surgery_Schwartz_12938 | Surgery_Schwartz | AL, Landi A. Osteoid osteoma of the hand and wrist. J Hand Surg Br. 2002;27(5):440-443. 97. Maloney WJ, Vaughan LM, Jones HH, Ross J, Nagel DA. Benign metastasizing giant-cell tumor of bone. Report of three cases and review of the literature. Clin Orthop Relat Res. 1989(243):208-215. 98. Oliveira VC, van der Heijden L, van der Geest IC, et al. Giant cell tumours of the small bones of the hands and feet: long-term results of 30 patients and a systematic literature review. Bone Joint J. 2013;95-b(6):838-845. 99. Ogose A, Unni KK, Swee RG, et al. Chondrosarcoma of small bones of the hands and feet. Cancer. 1997;80:50-59. 100. Okada K, Wold LE, Beabout JW, et al. Osteosarcoma of the hand: a clinicopathologic study of 12 cases. Cancer. 1993;72:719-725. 101. Amadio PC, Lombardi RM. Metastatic tumors of the hand. J Hand Surg Am. 1987;12:311-316. 102. Sheridan RL. Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands. Ann Surg. | Surgery_Schwartz. AL, Landi A. Osteoid osteoma of the hand and wrist. J Hand Surg Br. 2002;27(5):440-443. 97. Maloney WJ, Vaughan LM, Jones HH, Ross J, Nagel DA. Benign metastasizing giant-cell tumor of bone. Report of three cases and review of the literature. Clin Orthop Relat Res. 1989(243):208-215. 98. Oliveira VC, van der Heijden L, van der Geest IC, et al. Giant cell tumours of the small bones of the hands and feet: long-term results of 30 patients and a systematic literature review. Bone Joint J. 2013;95-b(6):838-845. 99. Ogose A, Unni KK, Swee RG, et al. Chondrosarcoma of small bones of the hands and feet. Cancer. 1997;80:50-59. 100. Okada K, Wold LE, Beabout JW, et al. Osteosarcoma of the hand: a clinicopathologic study of 12 cases. Cancer. 1993;72:719-725. 101. Amadio PC, Lombardi RM. Metastatic tumors of the hand. J Hand Surg Am. 1987;12:311-316. 102. Sheridan RL. Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands. Ann Surg. |
Surgery_Schwartz_12939 | Surgery_Schwartz | tumors of the hand. J Hand Surg Am. 1987;12:311-316. 102. Sheridan RL. Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands. Ann Surg. 1999;229:558-564. 103. Pan BS, Vu AT, Yakuboff KP. Management of the acutely burned hand. J Hand Surg Am. 2015;40(7):1477-1484; quiz 1485. 104. Herndon D. Total Burn Care. 2nd ed. London: WB Saunders; 2002. 105. Haslik W, Kamolz LP, Nathschläger G, et al. First experi-ences with the collagen-elastin matrix Matriderm as a der-mal substitute in severe burn injuries of the hand. Burns. 2007;33:364-368. 106. Robinson EP, Chhabra AB. Hand chemical burns. J Hand Surg Am. 2015;40(3):605-612; quiz 613. 107. Conn J Jr, Bergan JJ, Bell JL. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery. 1970;68(6):1122-1128. 108. Lifchez SD, Higgins JP. Long-term results of surgical treat-ment for hypothenar hammer syndrome. Plast Reconstr Surg. 2009;124(1):210-216. 109. Michelotti BM, Rizzo M, | Surgery_Schwartz. tumors of the hand. J Hand Surg Am. 1987;12:311-316. 102. Sheridan RL. Acute hand burns in children: management and long-term outcome based on a 10-year experience with 698 injured hands. Ann Surg. 1999;229:558-564. 103. Pan BS, Vu AT, Yakuboff KP. Management of the acutely burned hand. J Hand Surg Am. 2015;40(7):1477-1484; quiz 1485. 104. Herndon D. Total Burn Care. 2nd ed. London: WB Saunders; 2002. 105. Haslik W, Kamolz LP, Nathschläger G, et al. First experi-ences with the collagen-elastin matrix Matriderm as a der-mal substitute in severe burn injuries of the hand. Burns. 2007;33:364-368. 106. Robinson EP, Chhabra AB. Hand chemical burns. J Hand Surg Am. 2015;40(3):605-612; quiz 613. 107. Conn J Jr, Bergan JJ, Bell JL. Hypothenar hammer syndrome: posttraumatic digital ischemia. Surgery. 1970;68(6):1122-1128. 108. Lifchez SD, Higgins JP. Long-term results of surgical treat-ment for hypothenar hammer syndrome. Plast Reconstr Surg. 2009;124(1):210-216. 109. Michelotti BM, Rizzo M, |
Surgery_Schwartz_12940 | Surgery_Schwartz | 1970;68(6):1122-1128. 108. Lifchez SD, Higgins JP. Long-term results of surgical treat-ment for hypothenar hammer syndrome. Plast Reconstr Surg. 2009;124(1):210-216. 109. Michelotti BM, Rizzo M, Moran SL. Connective tissue disor-ders associated with vasculitis and vaso-occlusive disease of the hand. Hand Clin. 2015;31(1):63-73. 110. Hotchkiss R, Marks T. Management of acute and chronic vas-cular conditions of the hand. Curr Rev Musculoskelet Med. 2014;7(1):47-52. 111. Ruch DS, Holden M, Smith BP, et al. Periarterial sympathec-tomy in scleroderma patients: intermediate-term follow-up. J Hand Surg Am. 2002;27:258-264. 112. Uppal L, Dhaliwal K, Butler PE. A prospective study of the use of botulinum toxin injections in the treatment of Raynaud’s syndrome associated with scleroderma. J Hand Surg Eur Vol. 2014;39(8):876-880. 113. Ekblom AG, Laurell T, Arner M. Epidemiology of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population study from Stockholm, | Surgery_Schwartz. 1970;68(6):1122-1128. 108. Lifchez SD, Higgins JP. Long-term results of surgical treat-ment for hypothenar hammer syndrome. Plast Reconstr Surg. 2009;124(1):210-216. 109. Michelotti BM, Rizzo M, Moran SL. Connective tissue disor-ders associated with vasculitis and vaso-occlusive disease of the hand. Hand Clin. 2015;31(1):63-73. 110. Hotchkiss R, Marks T. Management of acute and chronic vas-cular conditions of the hand. Curr Rev Musculoskelet Med. 2014;7(1):47-52. 111. Ruch DS, Holden M, Smith BP, et al. Periarterial sympathec-tomy in scleroderma patients: intermediate-term follow-up. J Hand Surg Am. 2002;27:258-264. 112. Uppal L, Dhaliwal K, Butler PE. A prospective study of the use of botulinum toxin injections in the treatment of Raynaud’s syndrome associated with scleroderma. J Hand Surg Eur Vol. 2014;39(8):876-880. 113. Ekblom AG, Laurell T, Arner M. Epidemiology of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population study from Stockholm, |
Surgery_Schwartz_12941 | Surgery_Schwartz | Surg Eur Vol. 2014;39(8):876-880. 113. Ekblom AG, Laurell T, Arner M. Epidemiology of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population study from Stockholm, Sweden. J Hand Surg Am. 2010;35(11):1742-1754. 114. Swanson AB. A classification for congenital limb malfor-mations. J Hand Surg Am. 1976;1:8-22. Swanson developed the seven key categories for the organization of congenital limb malformations later adopted by the American Society for Surgery of the Hand. 115. Bates SJ, Hansen SL, Jones NF. Reconstruction of congeni-tal differences of the hand. Plast Reconstr Surg. 2009;124 (1 Suppl):128e-143e. 116. Wassel HD. The results of surgery for polydactyly of the thumb. A review. Clin Orthop Relat Res. 1969;64: 175-193. 117. Lee WP, Mathes DW. Hand transplantation: pertinent data and future outlook. J Hand Surg Am. 1999;24:906-913. 118. Malt RA, McKhann CF. Replantation of severed arms. JAMA. 1964;189:716.Brunicardi_Ch44_p1925-p1966.indd | Surgery_Schwartz. Surg Eur Vol. 2014;39(8):876-880. 113. Ekblom AG, Laurell T, Arner M. Epidemiology of congenital upper limb anomalies in 562 children born in 1997 to 2007: a total population study from Stockholm, Sweden. J Hand Surg Am. 2010;35(11):1742-1754. 114. Swanson AB. A classification for congenital limb malfor-mations. J Hand Surg Am. 1976;1:8-22. Swanson developed the seven key categories for the organization of congenital limb malformations later adopted by the American Society for Surgery of the Hand. 115. Bates SJ, Hansen SL, Jones NF. Reconstruction of congeni-tal differences of the hand. Plast Reconstr Surg. 2009;124 (1 Suppl):128e-143e. 116. Wassel HD. The results of surgery for polydactyly of the thumb. A review. Clin Orthop Relat Res. 1969;64: 175-193. 117. Lee WP, Mathes DW. Hand transplantation: pertinent data and future outlook. J Hand Surg Am. 1999;24:906-913. 118. Malt RA, McKhann CF. Replantation of severed arms. JAMA. 1964;189:716.Brunicardi_Ch44_p1925-p1966.indd |
Surgery_Schwartz_12942 | Surgery_Schwartz | Hand transplantation: pertinent data and future outlook. J Hand Surg Am. 1999;24:906-913. 118. Malt RA, McKhann CF. Replantation of severed arms. JAMA. 1964;189:716.Brunicardi_Ch44_p1925-p1966.indd 196520/02/19 2:50 PM 1966SPECIFIC CONSIDERATIONSPART II 119. Starzl TE, Fung J, Jordan M, et al. Kidney transplantation under FK 506. JAMA. 1990;264:63-67. 120. Gorantla VS, Brandacher G, Schneeberger S, et al. Favoring the risk-benefit balance for upper extremity transplantation: the Pittsburgh Protocol. Hand Clin. 2011;27:511-520. 121. Schneeberger S, Gorantla VS, Brandacher G, et al. Upperex-tremity transplantation using a cell-based protocol to mini-mize immunosuppression. Ann Surg. 2013;257:345-351. 122. Brandacher G, Lee WP, Schneeberger S. Minimizing immu-nosuppression in hand transplantation. Expert Rev Clin Immu-nol. 2012;8(7):673-683; quiz 684. 123. Shores JT. Recipient screening and selection: who is the right candidate for hand transplantation. Hand Clin. | Surgery_Schwartz. Hand transplantation: pertinent data and future outlook. J Hand Surg Am. 1999;24:906-913. 118. Malt RA, McKhann CF. Replantation of severed arms. JAMA. 1964;189:716.Brunicardi_Ch44_p1925-p1966.indd 196520/02/19 2:50 PM 1966SPECIFIC CONSIDERATIONSPART II 119. Starzl TE, Fung J, Jordan M, et al. Kidney transplantation under FK 506. JAMA. 1990;264:63-67. 120. Gorantla VS, Brandacher G, Schneeberger S, et al. Favoring the risk-benefit balance for upper extremity transplantation: the Pittsburgh Protocol. Hand Clin. 2011;27:511-520. 121. Schneeberger S, Gorantla VS, Brandacher G, et al. Upperex-tremity transplantation using a cell-based protocol to mini-mize immunosuppression. Ann Surg. 2013;257:345-351. 122. Brandacher G, Lee WP, Schneeberger S. Minimizing immu-nosuppression in hand transplantation. Expert Rev Clin Immu-nol. 2012;8(7):673-683; quiz 684. 123. Shores JT. Recipient screening and selection: who is the right candidate for hand transplantation. Hand Clin. |
Surgery_Schwartz_12943 | Surgery_Schwartz | in hand transplantation. Expert Rev Clin Immu-nol. 2012;8(7):673-683; quiz 684. 123. Shores JT. Recipient screening and selection: who is the right candidate for hand transplantation. Hand Clin. 2011;27:539-543.Brunicardi_Ch44_p1925-p1966.indd 196620/02/19 2:50 PM | Surgery_Schwartz. in hand transplantation. Expert Rev Clin Immu-nol. 2012;8(7):673-683; quiz 684. 123. Shores JT. Recipient screening and selection: who is the right candidate for hand transplantation. Hand Clin. 2011;27:539-543.Brunicardi_Ch44_p1925-p1966.indd 196620/02/19 2:50 PM |
Surgery_Schwartz_12944 | Surgery_Schwartz | Plastic and Reconstructive SurgeryRajiv Y. Chandawarkar, Michael J. Miller, Brian C. Kellogg, Steven A. Schulz, Ian L. Valerio, and Richard E. Kirschner 45chapterINTRODUCTIONPlastic and reconstructive surgery is a unique subspecialty of surgery that consists of a set of techniques intended to mod-ify the amount, position, quality, or organization of tissues in order to restore function and appearance. The name of the field is derived from the Greek word plastikos, which means “to mold.” An object is considered plastic if its shape can be modi-fied without destruction. In this sense, all human tissues have some degree of plasticity. They can be nondestructively modi-fied if the surgeon adheres to certain principles. Understanding and applying these principles to solve clinical problems is the essence of plastic and reconstructive surgery. Although informal references to this type of surgery can be found in the modern literature as early as the 17th century, American surgeon John | Surgery_Schwartz. Plastic and Reconstructive SurgeryRajiv Y. Chandawarkar, Michael J. Miller, Brian C. Kellogg, Steven A. Schulz, Ian L. Valerio, and Richard E. Kirschner 45chapterINTRODUCTIONPlastic and reconstructive surgery is a unique subspecialty of surgery that consists of a set of techniques intended to mod-ify the amount, position, quality, or organization of tissues in order to restore function and appearance. The name of the field is derived from the Greek word plastikos, which means “to mold.” An object is considered plastic if its shape can be modi-fied without destruction. In this sense, all human tissues have some degree of plasticity. They can be nondestructively modi-fied if the surgeon adheres to certain principles. Understanding and applying these principles to solve clinical problems is the essence of plastic and reconstructive surgery. Although informal references to this type of surgery can be found in the modern literature as early as the 17th century, American surgeon John |
Surgery_Schwartz_12945 | Surgery_Schwartz | is the essence of plastic and reconstructive surgery. Although informal references to this type of surgery can be found in the modern literature as early as the 17th century, American surgeon John Staige Davis published the first textbook dedicated to the field in 1919, entitled Plastic Surgery—Its Principles and Practice. He coined the term that we have used to refer to the specialty ever since. Science has always evolved in a nonlinear fashion: seminal discoveries in different parts of the world have all col-lectively fueled progress and addressed an unmet need. The evolution of plastic and reconstructive surgery has followed the same path: the Edwin Smith Papyrus1 (Egypt, 1600 b.c.) (Fig. 45-1) described facial reconstruction; the Shushruta Samhita (India, 1500 b.c.) (Fig. 45-2) described nasal reconstruction; and Aulus Cornelius Celsus (Rome, 1 a.d.) described opera-tions for facial reconstruction. The underlying impetus for this evolution is the common unmet need for restoring | Surgery_Schwartz. is the essence of plastic and reconstructive surgery. Although informal references to this type of surgery can be found in the modern literature as early as the 17th century, American surgeon John Staige Davis published the first textbook dedicated to the field in 1919, entitled Plastic Surgery—Its Principles and Practice. He coined the term that we have used to refer to the specialty ever since. Science has always evolved in a nonlinear fashion: seminal discoveries in different parts of the world have all col-lectively fueled progress and addressed an unmet need. The evolution of plastic and reconstructive surgery has followed the same path: the Edwin Smith Papyrus1 (Egypt, 1600 b.c.) (Fig. 45-1) described facial reconstruction; the Shushruta Samhita (India, 1500 b.c.) (Fig. 45-2) described nasal reconstruction; and Aulus Cornelius Celsus (Rome, 1 a.d.) described opera-tions for facial reconstruction. The underlying impetus for this evolution is the common unmet need for restoring |
Surgery_Schwartz_12946 | Surgery_Schwartz | nasal reconstruction; and Aulus Cornelius Celsus (Rome, 1 a.d.) described opera-tions for facial reconstruction. The underlying impetus for this evolution is the common unmet need for restoring defects, be they congenital, traumatic, or functional.This strong thread of advances in reconstructive surgery continues even today. What does seem under-recognized is that the clinical practice of plastic and reconstructive surgery touches on every other area of surgery. Enhanced reconstructive capabilities strengthen all other specialties significantly, such as the ability to safely perform radical cancer operations, sal-vage traumatic limbs, or extend the reach of neonatal medicine by congenital reconstruction. Each surgical specialty encoun-ters problems that might be addressed by some form of tissue repair, modification, rearrangement, transfer, or replacement. Since its inception, plastic surgeons have routinely responded to the medical needs of the society and helped restore form and | Surgery_Schwartz. nasal reconstruction; and Aulus Cornelius Celsus (Rome, 1 a.d.) described opera-tions for facial reconstruction. The underlying impetus for this evolution is the common unmet need for restoring defects, be they congenital, traumatic, or functional.This strong thread of advances in reconstructive surgery continues even today. What does seem under-recognized is that the clinical practice of plastic and reconstructive surgery touches on every other area of surgery. Enhanced reconstructive capabilities strengthen all other specialties significantly, such as the ability to safely perform radical cancer operations, sal-vage traumatic limbs, or extend the reach of neonatal medicine by congenital reconstruction. Each surgical specialty encoun-ters problems that might be addressed by some form of tissue repair, modification, rearrangement, transfer, or replacement. Since its inception, plastic surgeons have routinely responded to the medical needs of the society and helped restore form and |
Surgery_Schwartz_12947 | Surgery_Schwartz | of tissue repair, modification, rearrangement, transfer, or replacement. Since its inception, plastic surgeons have routinely responded to the medical needs of the society and helped restore form and function. One of the most powerful examples of this response is the advances that occurred as a result of World Wars I and II. Walter Yeo, a sailor injured at the Battle of Jutland, is assumed to have received plastic surgery in 1917. The photograph shows him before (Fig. 45-3, left) and after (right) receiving a flap surgery performed by Gillies.The Gulf war and the conflicts in the Middle East have prompted several revolutionary reconstructive surgical advances in limb salvage, microsurgery, supermicrosurgery, hand, face, and abdominal wall transplantation. Plastic surgeons have also targeted muscle reinnervation, tissue engineering, and regenera-tive medicine.When society calls, plastic surgeons rise to the challenge and create novel methods to address its needs. For example, | Surgery_Schwartz. of tissue repair, modification, rearrangement, transfer, or replacement. Since its inception, plastic surgeons have routinely responded to the medical needs of the society and helped restore form and function. One of the most powerful examples of this response is the advances that occurred as a result of World Wars I and II. Walter Yeo, a sailor injured at the Battle of Jutland, is assumed to have received plastic surgery in 1917. The photograph shows him before (Fig. 45-3, left) and after (right) receiving a flap surgery performed by Gillies.The Gulf war and the conflicts in the Middle East have prompted several revolutionary reconstructive surgical advances in limb salvage, microsurgery, supermicrosurgery, hand, face, and abdominal wall transplantation. Plastic surgeons have also targeted muscle reinnervation, tissue engineering, and regenera-tive medicine.When society calls, plastic surgeons rise to the challenge and create novel methods to address its needs. For example, |
Surgery_Schwartz_12948 | Surgery_Schwartz | targeted muscle reinnervation, tissue engineering, and regenera-tive medicine.When society calls, plastic surgeons rise to the challenge and create novel methods to address its needs. For example, neurosurgeons at times must replace or stabilize bone in the cranium or spine, and healthy soft tissue coverage is essen-tial for optimal healing. Head and neck surgeons face tissue replacement problems in order to restore normal function and appearance after major tumor ablation. Thoracic surgeons must manage bronchopleural fistulae, esophageal defects, or loss of chest wall integrity after trauma or tumor resection. Cardiolo-gists and cardiac surgeons at times face complicated wound Introduction 1967Purpose 1969General Principles 1969Skin Incisions / 1969Incision Repair / 1970Wound Healing / 1971Phases of Wound Healing / 1971Reconstructive Surgery 1974Reconstructive Strategies and Methods 1974Skin Grafts and Skin Substitutes / 1975Pediatric Plastic Surgery 1981Congenital Craniofacial | Surgery_Schwartz. targeted muscle reinnervation, tissue engineering, and regenera-tive medicine.When society calls, plastic surgeons rise to the challenge and create novel methods to address its needs. For example, neurosurgeons at times must replace or stabilize bone in the cranium or spine, and healthy soft tissue coverage is essen-tial for optimal healing. Head and neck surgeons face tissue replacement problems in order to restore normal function and appearance after major tumor ablation. Thoracic surgeons must manage bronchopleural fistulae, esophageal defects, or loss of chest wall integrity after trauma or tumor resection. Cardiolo-gists and cardiac surgeons at times face complicated wound Introduction 1967Purpose 1969General Principles 1969Skin Incisions / 1969Incision Repair / 1970Wound Healing / 1971Phases of Wound Healing / 1971Reconstructive Surgery 1974Reconstructive Strategies and Methods 1974Skin Grafts and Skin Substitutes / 1975Pediatric Plastic Surgery 1981Congenital Craniofacial |
Surgery_Schwartz_12949 | Surgery_Schwartz | / 1971Phases of Wound Healing / 1971Reconstructive Surgery 1974Reconstructive Strategies and Methods 1974Skin Grafts and Skin Substitutes / 1975Pediatric Plastic Surgery 1981Congenital Craniofacial Anomalies / 1981Reconstructive Surgery in Adults 2001Maxillofacial injuries and Fractures / 2002Mandible Fractures / 2002Frontal Sinus Fractures / 2003Orbital Fractures / 2004Zygomaticomaxillary Complex Fractures / 2004Nasoorbitalethmoid and Panfacial Fractures / 2005Posttraumatic Extremity Reconstruction / 2005Oncologic Reconstructive Surgery / 2008Breast Reconstruction / 2009Oncoplastic Breast Reconstruction / 2009Implant-based Reconstruction / 2009Tissue Flaps and Breast Implants / 2010Autologous Tissue Reconstruction / 2010Accessory Procedures / 2011Trunk and Abdominal Reconstruction / 2011Pelvic Reconstruction / 2012Other Clinical Circumstances / 2012Aesthetic Surgery and Medicine 2016Aesthetic Surgery of the Face / 2017Aesthetic Surgery of the Breast / 2018Aesthetic Surgery of | Surgery_Schwartz. / 1971Phases of Wound Healing / 1971Reconstructive Surgery 1974Reconstructive Strategies and Methods 1974Skin Grafts and Skin Substitutes / 1975Pediatric Plastic Surgery 1981Congenital Craniofacial Anomalies / 1981Reconstructive Surgery in Adults 2001Maxillofacial injuries and Fractures / 2002Mandible Fractures / 2002Frontal Sinus Fractures / 2003Orbital Fractures / 2004Zygomaticomaxillary Complex Fractures / 2004Nasoorbitalethmoid and Panfacial Fractures / 2005Posttraumatic Extremity Reconstruction / 2005Oncologic Reconstructive Surgery / 2008Breast Reconstruction / 2009Oncoplastic Breast Reconstruction / 2009Implant-based Reconstruction / 2009Tissue Flaps and Breast Implants / 2010Autologous Tissue Reconstruction / 2010Accessory Procedures / 2011Trunk and Abdominal Reconstruction / 2011Pelvic Reconstruction / 2012Other Clinical Circumstances / 2012Aesthetic Surgery and Medicine 2016Aesthetic Surgery of the Face / 2017Aesthetic Surgery of the Breast / 2018Aesthetic Surgery of |
Surgery_Schwartz_12950 | Surgery_Schwartz | / 2011Pelvic Reconstruction / 2012Other Clinical Circumstances / 2012Aesthetic Surgery and Medicine 2016Aesthetic Surgery of the Face / 2017Aesthetic Surgery of the Breast / 2018Aesthetic Surgery of the Body / 2018Suction Lipectomy / 2022Autologous Fat Grafting / 2024Brunicardi_Ch45_p1967-p2026.indd 196701/03/19 6:26 PM 1968Figure 45-1. The Edwin Smith papyrus (Egypt, 1600 b.c.).Figure 45-2. Statue of Shushruta, considered the “founding father of surgery” in India.Key Points1 It is critical to understand the physiologic basis and ratio-nale of wound healing in order to further assimilate surgi-cal and nonsurgical care of wounds and methods of wound care.2 Understanding the reconstructive choices in tissue repair cases is critical for any surgeon. The principles of soft tis-sue and skin repair are important for the reconstruction of defects, whether in a trauma situation of after excision of lesions.3 Children with cleft and craniofacial differences have com-plex medical, surgical, | Surgery_Schwartz. / 2011Pelvic Reconstruction / 2012Other Clinical Circumstances / 2012Aesthetic Surgery and Medicine 2016Aesthetic Surgery of the Face / 2017Aesthetic Surgery of the Breast / 2018Aesthetic Surgery of the Body / 2018Suction Lipectomy / 2022Autologous Fat Grafting / 2024Brunicardi_Ch45_p1967-p2026.indd 196701/03/19 6:26 PM 1968Figure 45-1. The Edwin Smith papyrus (Egypt, 1600 b.c.).Figure 45-2. Statue of Shushruta, considered the “founding father of surgery” in India.Key Points1 It is critical to understand the physiologic basis and ratio-nale of wound healing in order to further assimilate surgi-cal and nonsurgical care of wounds and methods of wound care.2 Understanding the reconstructive choices in tissue repair cases is critical for any surgeon. The principles of soft tis-sue and skin repair are important for the reconstruction of defects, whether in a trauma situation of after excision of lesions.3 Children with cleft and craniofacial differences have com-plex medical, surgical, |
Surgery_Schwartz_12951 | Surgery_Schwartz | repair are important for the reconstruction of defects, whether in a trauma situation of after excision of lesions.3 Children with cleft and craniofacial differences have com-plex medical, surgical, and social needs. Coordinated, interdisciplinary team care is crucial to success.4 Robin sequence, characterized by micrognathia, glossop-tosis, and airway obstruction, can be managed with prone positioning, tongue-lip adhesion, mandibular distraction osteogenesis, or tracheostomy.5 The first-line treatment for high-risk hemangiomas is oral propranolol, which can induce rapid involution and has a more favorable side effect profile than systemic steroids.6 The coordination of care for patients in a trauma depart-ment is an important part of a surgeon’s role, whether that role be as a trauma emergency department surgeon or a surgeon in practice.7 The careful evaluation of a patient in a polytrauma involves a thorough assessment of internal and soft tissue injuries, planning of care, and the | Surgery_Schwartz. repair are important for the reconstruction of defects, whether in a trauma situation of after excision of lesions.3 Children with cleft and craniofacial differences have com-plex medical, surgical, and social needs. Coordinated, interdisciplinary team care is crucial to success.4 Robin sequence, characterized by micrognathia, glossop-tosis, and airway obstruction, can be managed with prone positioning, tongue-lip adhesion, mandibular distraction osteogenesis, or tracheostomy.5 The first-line treatment for high-risk hemangiomas is oral propranolol, which can induce rapid involution and has a more favorable side effect profile than systemic steroids.6 The coordination of care for patients in a trauma depart-ment is an important part of a surgeon’s role, whether that role be as a trauma emergency department surgeon or a surgeon in practice.7 The careful evaluation of a patient in a polytrauma involves a thorough assessment of internal and soft tissue injuries, planning of care, and the |
Surgery_Schwartz_12952 | Surgery_Schwartz | department surgeon or a surgeon in practice.7 The careful evaluation of a patient in a polytrauma involves a thorough assessment of internal and soft tissue injuries, planning of care, and the appropriate triage of reconstructive procedures. As a leader in a trauma bay of the trauma service, the surgeon typically assumes a cap-tain’s role in decision-making.8 Principles of oncologic reconstruction have evolved sig-nificantly, and a deeper understanding of these reconstruc-tive choices is essential for a surgeon who is often the first point of contact for cancer patients and responsible for making critical referrals.9 The combined work of general surgeons and reconstruc-tive plastic surgeons has revolutionized the care of abdom-inal wall defects, including ventral hernias, repair after tumor ablation, and bariatric surgery.10 Any critical care unit or a medical surgical team that takes care of debilitated patients needs a detailed understanding of pressure sores, including their | Surgery_Schwartz. department surgeon or a surgeon in practice.7 The careful evaluation of a patient in a polytrauma involves a thorough assessment of internal and soft tissue injuries, planning of care, and the appropriate triage of reconstructive procedures. As a leader in a trauma bay of the trauma service, the surgeon typically assumes a cap-tain’s role in decision-making.8 Principles of oncologic reconstruction have evolved sig-nificantly, and a deeper understanding of these reconstruc-tive choices is essential for a surgeon who is often the first point of contact for cancer patients and responsible for making critical referrals.9 The combined work of general surgeons and reconstruc-tive plastic surgeons has revolutionized the care of abdom-inal wall defects, including ventral hernias, repair after tumor ablation, and bariatric surgery.10 Any critical care unit or a medical surgical team that takes care of debilitated patients needs a detailed understanding of pressure sores, including their |
Surgery_Schwartz_12953 | Surgery_Schwartz | tumor ablation, and bariatric surgery.10 Any critical care unit or a medical surgical team that takes care of debilitated patients needs a detailed understanding of pressure sores, including their etiology and the recon-structive options that are available to these patients.infections, sternal osteomyelitis, or failure of soft tissue cov-erage that leads to exposure and contamination of implanted devices such as left ventricular assist devices or cardiac pace-makers. Orthopedic surgeons managing segmental bone defects in the extremities at times require replacement by surgical transfer of vascularized bone segments rather than conventional bone grafts or alloplastic substitutes. Urologists, colorectal sur-geons, and gynecologists who commonly perform surgery in the perineum encounter nonhealing wounds or fistulae. All of these problems may be managed or potentially prevented by judicious application of tissue methods developed and practiced by plastic and reconstructive | Surgery_Schwartz. tumor ablation, and bariatric surgery.10 Any critical care unit or a medical surgical team that takes care of debilitated patients needs a detailed understanding of pressure sores, including their etiology and the recon-structive options that are available to these patients.infections, sternal osteomyelitis, or failure of soft tissue cov-erage that leads to exposure and contamination of implanted devices such as left ventricular assist devices or cardiac pace-makers. Orthopedic surgeons managing segmental bone defects in the extremities at times require replacement by surgical transfer of vascularized bone segments rather than conventional bone grafts or alloplastic substitutes. Urologists, colorectal sur-geons, and gynecologists who commonly perform surgery in the perineum encounter nonhealing wounds or fistulae. All of these problems may be managed or potentially prevented by judicious application of tissue methods developed and practiced by plastic and reconstructive |
Surgery_Schwartz_12954 | Surgery_Schwartz | encounter nonhealing wounds or fistulae. All of these problems may be managed or potentially prevented by judicious application of tissue methods developed and practiced by plastic and reconstructive surgeons.Plastic and reconstructive surgery is field characterized by innovation, and it has yielded important contributions to other surgical specialties. These include notable advances in hand and upper extremity surgery, craniofacial surgery, peripheral nerve surgery, and reconstructive microsurgery. Entirely new fields of have emerged from plastic surgery research. Joseph E. Murray, a Boston plastic surgeon, and his team performed the first renal transplantation procedures and laid the foundation for modern organ transplantation, an achievement for which he was awarded the Nobel Prize in Medicine in 1990 (Fig. 45-4). This spirit of innovation continues with ongoing active research by plastic surgeons in composite tissue allotransplantation, tis-sue engineering, biomaterials, cell | Surgery_Schwartz. encounter nonhealing wounds or fistulae. All of these problems may be managed or potentially prevented by judicious application of tissue methods developed and practiced by plastic and reconstructive surgeons.Plastic and reconstructive surgery is field characterized by innovation, and it has yielded important contributions to other surgical specialties. These include notable advances in hand and upper extremity surgery, craniofacial surgery, peripheral nerve surgery, and reconstructive microsurgery. Entirely new fields of have emerged from plastic surgery research. Joseph E. Murray, a Boston plastic surgeon, and his team performed the first renal transplantation procedures and laid the foundation for modern organ transplantation, an achievement for which he was awarded the Nobel Prize in Medicine in 1990 (Fig. 45-4). This spirit of innovation continues with ongoing active research by plastic surgeons in composite tissue allotransplantation, tis-sue engineering, biomaterials, cell |
Surgery_Schwartz_12955 | Surgery_Schwartz | in Medicine in 1990 (Fig. 45-4). This spirit of innovation continues with ongoing active research by plastic surgeons in composite tissue allotransplantation, tis-sue engineering, biomaterials, cell transplantation, regenerative medicine, computer-assisted surgical planning, medical appli-cation of three-dimensional manufacturing methods, infection control, and outcomes research. Plastic and reconstructive sur-gery is a vibrant field that brings tremendous value to people’s health and quality of life through life-changing reconstructive, restorative, and transformative surgeries.Brunicardi_Ch45_p1967-p2026.indd 196801/03/19 6:26 PM 1969PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-3. Walter Yeo, a sailor injured at the Battle of Jutland in 1917.Figure 45-4. Joseph E. Murray, MD, awarded the Nobel Prize in Medicine in 1990.PURPOSEThe purpose of this chapter is to inform about the general prin-ciples of plastic and reconstructive surgery, which apply to all areas of surgery, | Surgery_Schwartz. in Medicine in 1990 (Fig. 45-4). This spirit of innovation continues with ongoing active research by plastic surgeons in composite tissue allotransplantation, tis-sue engineering, biomaterials, cell transplantation, regenerative medicine, computer-assisted surgical planning, medical appli-cation of three-dimensional manufacturing methods, infection control, and outcomes research. Plastic and reconstructive sur-gery is a vibrant field that brings tremendous value to people’s health and quality of life through life-changing reconstructive, restorative, and transformative surgeries.Brunicardi_Ch45_p1967-p2026.indd 196801/03/19 6:26 PM 1969PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-3. Walter Yeo, a sailor injured at the Battle of Jutland in 1917.Figure 45-4. Joseph E. Murray, MD, awarded the Nobel Prize in Medicine in 1990.PURPOSEThe purpose of this chapter is to inform about the general prin-ciples of plastic and reconstructive surgery, which apply to all areas of surgery, |
Surgery_Schwartz_12956 | Surgery_Schwartz | awarded the Nobel Prize in Medicine in 1990.PURPOSEThe purpose of this chapter is to inform about the general prin-ciples of plastic and reconstructive surgery, which apply to all areas of surgery, and to provide current examples of practice. Studying this chapter will help the reader to understand (a) the principles of plastic surgery that translate into other surgi-cal specialties; (b) the kind of clinical problems that may be addressed using plastic surgery techniques; and (c) the types of research found in plastic and reconstructive surgery. It will make clearer the nature of the field and its role in the multidis-ciplinary care environment of modern healthcare.GENERAL PRINCIPLESGeneral principles of plastic surgery relate to technical aspects of incision planning and wound repair. These principles apply to all surgical disciplines. As such, every surgeon can benefit from learning and applying them. Previously, tremendous emphasis was placed on simply understanding the nature of | Surgery_Schwartz. awarded the Nobel Prize in Medicine in 1990.PURPOSEThe purpose of this chapter is to inform about the general prin-ciples of plastic and reconstructive surgery, which apply to all areas of surgery, and to provide current examples of practice. Studying this chapter will help the reader to understand (a) the principles of plastic surgery that translate into other surgi-cal specialties; (b) the kind of clinical problems that may be addressed using plastic surgery techniques; and (c) the types of research found in plastic and reconstructive surgery. It will make clearer the nature of the field and its role in the multidis-ciplinary care environment of modern healthcare.GENERAL PRINCIPLESGeneral principles of plastic surgery relate to technical aspects of incision planning and wound repair. These principles apply to all surgical disciplines. As such, every surgeon can benefit from learning and applying them. Previously, tremendous emphasis was placed on simply understanding the nature of |
Surgery_Schwartz_12957 | Surgery_Schwartz | principles apply to all surgical disciplines. As such, every surgeon can benefit from learning and applying them. Previously, tremendous emphasis was placed on simply understanding the nature of skin, which is completely justified; however, over the past few years plastic surgical focus has expanded to include the entire integument. Muscles, fascia, fat, skeletal framework, nerves, vascular net-works, and their dynamic interactions have become far more important factors that are choreographed in most reconstructive processes.Skin IncisionsFrom a surgical viewpoint, the skin is a multilayered tissue formed by dermis and epidermis. It is the largest organ in the human body and exists in a state of dynamic equilibrium from the balance of tension created by external and internal factors. Externally, skin and underlying subcutaneous tissue are acted on by gravity and clothing. Internal factors include skin elasticity, which is simply the ability to stretch and return to prestretch | Surgery_Schwartz. principles apply to all surgical disciplines. As such, every surgeon can benefit from learning and applying them. Previously, tremendous emphasis was placed on simply understanding the nature of skin, which is completely justified; however, over the past few years plastic surgical focus has expanded to include the entire integument. Muscles, fascia, fat, skeletal framework, nerves, vascular net-works, and their dynamic interactions have become far more important factors that are choreographed in most reconstructive processes.Skin IncisionsFrom a surgical viewpoint, the skin is a multilayered tissue formed by dermis and epidermis. It is the largest organ in the human body and exists in a state of dynamic equilibrium from the balance of tension created by external and internal factors. Externally, skin and underlying subcutaneous tissue are acted on by gravity and clothing. Internal factors include skin elasticity, which is simply the ability to stretch and return to prestretch |
Surgery_Schwartz_12958 | Surgery_Schwartz | Externally, skin and underlying subcutaneous tissue are acted on by gravity and clothing. Internal factors include skin elasticity, which is simply the ability to stretch and return to prestretch architecture upon removal of the stretch. The dermis is com-posed of different types of collagen and elastic protein fibers (elastin), and epidermis, composed primarily of cells anchored together in various stages of maturation. The skin serves impor-tant functions of thermoregulation, affording tactile sensation, and protection from foreign materials and microorganisms. Areas of skin exposed to view in normal clothing play a sig-nificant role in personal appearance and social interaction. As a result, even favorable scars from surgical incisions can have an undesirable effect on personal appearance. Thoughtful place-ment and performance of a surgical incision will minimize the risk of adverse consequences that can result in shortand long-term morbidity.Human skin exists in a resting state of | Surgery_Schwartz. Externally, skin and underlying subcutaneous tissue are acted on by gravity and clothing. Internal factors include skin elasticity, which is simply the ability to stretch and return to prestretch architecture upon removal of the stretch. The dermis is com-posed of different types of collagen and elastic protein fibers (elastin), and epidermis, composed primarily of cells anchored together in various stages of maturation. The skin serves impor-tant functions of thermoregulation, affording tactile sensation, and protection from foreign materials and microorganisms. Areas of skin exposed to view in normal clothing play a sig-nificant role in personal appearance and social interaction. As a result, even favorable scars from surgical incisions can have an undesirable effect on personal appearance. Thoughtful place-ment and performance of a surgical incision will minimize the risk of adverse consequences that can result in shortand long-term morbidity.Human skin exists in a resting state of |
Surgery_Schwartz_12959 | Surgery_Schwartz | Thoughtful place-ment and performance of a surgical incision will minimize the risk of adverse consequences that can result in shortand long-term morbidity.Human skin exists in a resting state of tension caused by gravity and its conformation over underlying structures between sites that are tethered by subcutaneous fibrous tissue, which secure the deep surface of the dermis to underlying points of fixation. When the skin is incised linearly, the wound edges separate in a predicable fashion forming an ellipse with the long axis perpendicular to the lines of greatest tension. These tension lines are often called “Langer’s lines,” after Carl Langer, a 19th century anatomist from Vienna who first described them based on studies in fresh cadavers (Fig. 45-5). Later, Borges described relaxed skin tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. Inci-sions placed parallel to these lines often heal with less conspicu-ous scar because | Surgery_Schwartz. Thoughtful place-ment and performance of a surgical incision will minimize the risk of adverse consequences that can result in shortand long-term morbidity.Human skin exists in a resting state of tension caused by gravity and its conformation over underlying structures between sites that are tethered by subcutaneous fibrous tissue, which secure the deep surface of the dermis to underlying points of fixation. When the skin is incised linearly, the wound edges separate in a predicable fashion forming an ellipse with the long axis perpendicular to the lines of greatest tension. These tension lines are often called “Langer’s lines,” after Carl Langer, a 19th century anatomist from Vienna who first described them based on studies in fresh cadavers (Fig. 45-5). Later, Borges described relaxed skin tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. Inci-sions placed parallel to these lines often heal with less conspicu-ous scar because |
Surgery_Schwartz_12960 | Surgery_Schwartz | tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. Inci-sions placed parallel to these lines often heal with less conspicu-ous scar because the skin often has natural wrinkles following these lines and there is less tension perpendicular to the orien-tation of the wound1 (Fig. 45-6). Based on these principles,2 a recommended pattern for incisions can be made (Fig. 45-7).Using the proper technique for creating and repairing skin incisions ensures uncomplicated wound healing with few distorting surface scars. The epidermis and superficial dermis should be incised sharply with a scalpel. The incision is then continued through the deep dermis and subdermal plexus of blood vessels with electrocautery. This technique helps to mini-mize collateral tissue injury along the wound margins to facili-tate prompt and reliable healing. It is essential to maintain the orientation of the scalpel or electrocautery blade perpendicular to the | Surgery_Schwartz. tension lines, which follow furrows formed when the skin is relaxed and are produced by pinching the skin. Inci-sions placed parallel to these lines often heal with less conspicu-ous scar because the skin often has natural wrinkles following these lines and there is less tension perpendicular to the orien-tation of the wound1 (Fig. 45-6). Based on these principles,2 a recommended pattern for incisions can be made (Fig. 45-7).Using the proper technique for creating and repairing skin incisions ensures uncomplicated wound healing with few distorting surface scars. The epidermis and superficial dermis should be incised sharply with a scalpel. The incision is then continued through the deep dermis and subdermal plexus of blood vessels with electrocautery. This technique helps to mini-mize collateral tissue injury along the wound margins to facili-tate prompt and reliable healing. It is essential to maintain the orientation of the scalpel or electrocautery blade perpendicular to the |
Surgery_Schwartz_12961 | Surgery_Schwartz | collateral tissue injury along the wound margins to facili-tate prompt and reliable healing. It is essential to maintain the orientation of the scalpel or electrocautery blade perpendicular to the surface of the skin in order to facilitate accurate reap-proximation during wound closure. As the incision is deepened through the subcutaneous tissue to expose underlying structures, it is important to avoid creating multiple pathways through the tissue, which can create focal areas of devitalized tissue that form a nidus of infection or lead to delayed wound healing. The Brunicardi_Ch45_p1967-p2026.indd 196901/03/19 6:26 PM 1970SPECIFIC CONSIDERATIONSPART IIFigure 45-5. “Langer’s lines,” named after Carl Langer, a 19th century anatomist from Vienna.Figure 45-6. Lines of relaxed skin tension.Figure 45-7. Planning of incisions based on lines of skin tension.surgeon should extend the incision through the subcutaneous fat by tracing the same line each time with the scalpel or | Surgery_Schwartz. collateral tissue injury along the wound margins to facili-tate prompt and reliable healing. It is essential to maintain the orientation of the scalpel or electrocautery blade perpendicular to the surface of the skin in order to facilitate accurate reap-proximation during wound closure. As the incision is deepened through the subcutaneous tissue to expose underlying structures, it is important to avoid creating multiple pathways through the tissue, which can create focal areas of devitalized tissue that form a nidus of infection or lead to delayed wound healing. The Brunicardi_Ch45_p1967-p2026.indd 196901/03/19 6:26 PM 1970SPECIFIC CONSIDERATIONSPART IIFigure 45-5. “Langer’s lines,” named after Carl Langer, a 19th century anatomist from Vienna.Figure 45-6. Lines of relaxed skin tension.Figure 45-7. Planning of incisions based on lines of skin tension.surgeon should extend the incision through the subcutaneous fat by tracing the same line each time with the scalpel or |
Surgery_Schwartz_12962 | Surgery_Schwartz | skin tension.Figure 45-7. Planning of incisions based on lines of skin tension.surgeon should extend the incision through the subcutaneous fat by tracing the same line each time with the scalpel or electrocau-tery in order to reach the deeper structures.Traumatic wounds do not permit the same careful plan-ning that is possible with incisions made in undamaged skin. Nevertheless, optimum repair of traumatic lacerations involves similar principles applicable in nontraumatic circumstances. The surgeon must remove as much traumatized tissue as pos-sible from the wound edges, converting the uncontrolled trau-matic wound into a controlled surgical wound. All devitalized tissue is excised. The same principles of making incisions perpendicular to the skin surface and avoiding creating mul-tiple pathways through the subcutaneous tissues apply. In this process, an attempt can be made to reorient the wound into a more favorable direction. A variety of methods are available to perform this | Surgery_Schwartz. skin tension.Figure 45-7. Planning of incisions based on lines of skin tension.surgeon should extend the incision through the subcutaneous fat by tracing the same line each time with the scalpel or electrocau-tery in order to reach the deeper structures.Traumatic wounds do not permit the same careful plan-ning that is possible with incisions made in undamaged skin. Nevertheless, optimum repair of traumatic lacerations involves similar principles applicable in nontraumatic circumstances. The surgeon must remove as much traumatized tissue as pos-sible from the wound edges, converting the uncontrolled trau-matic wound into a controlled surgical wound. All devitalized tissue is excised. The same principles of making incisions perpendicular to the skin surface and avoiding creating mul-tiple pathways through the subcutaneous tissues apply. In this process, an attempt can be made to reorient the wound into a more favorable direction. A variety of methods are available to perform this |
Surgery_Schwartz_12963 | Surgery_Schwartz | pathways through the subcutaneous tissues apply. In this process, an attempt can be made to reorient the wound into a more favorable direction. A variety of methods are available to perform this reorientation, and they often involve creating small local flaps of undamaged tissue using geometric tissue rearrangements. These techniques will be considered later in this chapter. Following these principles increases the likelihood of uncomplicated wound healing and reduces the need for later treatment of unfavorable scars. However, there are situations in which the direction of the incision has been preestablished, as in acute lacerations, burns, or old contracted and distorting scars. In these circumstances, the principles of proper incision placement can be combined with simple surgical techniques to reorient the scar and lessen the deformity.When making an incision in an area of previous scar-ring, such as in a scar revision or a reoperation, it is preferable to completely excise the | Surgery_Schwartz. pathways through the subcutaneous tissues apply. In this process, an attempt can be made to reorient the wound into a more favorable direction. A variety of methods are available to perform this reorientation, and they often involve creating small local flaps of undamaged tissue using geometric tissue rearrangements. These techniques will be considered later in this chapter. Following these principles increases the likelihood of uncomplicated wound healing and reduces the need for later treatment of unfavorable scars. However, there are situations in which the direction of the incision has been preestablished, as in acute lacerations, burns, or old contracted and distorting scars. In these circumstances, the principles of proper incision placement can be combined with simple surgical techniques to reorient the scar and lessen the deformity.When making an incision in an area of previous scar-ring, such as in a scar revision or a reoperation, it is preferable to completely excise the |
Surgery_Schwartz_12964 | Surgery_Schwartz | to reorient the scar and lessen the deformity.When making an incision in an area of previous scar-ring, such as in a scar revision or a reoperation, it is preferable to completely excise the scar when making the skin incision and not simply make the incision through the old scar. Closing scarred wound edges increases the likelihood of delayed wound healing, infections, and unfavorable new scars. It only takes a few moments to make the skin incision outside of the area of scarring through unscarred skin. Once the skin incisions on each side of the previous scar reach into the subcutaneous tissue, then the surface scar can be removed completely at the subder-mal level. This approach ensures that the final repair relies on undamaged tissues, thus facilitating uncomplicated healing and lowering the risk of an unfavorable scar.Incision RepairA well-performed skin incision sets the stage for an accurate repair that minimizes the risk of unfavorable scarring. An unfa-vorable scar is | Surgery_Schwartz. to reorient the scar and lessen the deformity.When making an incision in an area of previous scar-ring, such as in a scar revision or a reoperation, it is preferable to completely excise the scar when making the skin incision and not simply make the incision through the old scar. Closing scarred wound edges increases the likelihood of delayed wound healing, infections, and unfavorable new scars. It only takes a few moments to make the skin incision outside of the area of scarring through unscarred skin. Once the skin incisions on each side of the previous scar reach into the subcutaneous tissue, then the surface scar can be removed completely at the subder-mal level. This approach ensures that the final repair relies on undamaged tissues, thus facilitating uncomplicated healing and lowering the risk of an unfavorable scar.Incision RepairA well-performed skin incision sets the stage for an accurate repair that minimizes the risk of unfavorable scarring. An unfa-vorable scar is |
Surgery_Schwartz_12965 | Surgery_Schwartz | lowering the risk of an unfavorable scar.Incision RepairA well-performed skin incision sets the stage for an accurate repair that minimizes the risk of unfavorable scarring. An unfa-vorable scar is characterized by excessive amount of collagen Brunicardi_Ch45_p1967-p2026.indd 197001/03/19 6:26 PM 1971PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45deposition,4 leading to hypertrophic scarring or keloid formation (Fig. 45-8). The difference between them is that a hypertrophic scar stops growing 6 months after the injury, whereas a keloid continues to grow, even growing well beyond its borders. Accu-rate approximation and stabilization of the skin edges helps to minimize the amount of collagen deposition required for skin healing. The most important layer to approximate is the dermis because this layer contains the healing elements such as blood supply and cellular elements that create the extracellular matrix necessary for healing. Optimal wound closure involves placing deep dermal | Surgery_Schwartz. lowering the risk of an unfavorable scar.Incision RepairA well-performed skin incision sets the stage for an accurate repair that minimizes the risk of unfavorable scarring. An unfa-vorable scar is characterized by excessive amount of collagen Brunicardi_Ch45_p1967-p2026.indd 197001/03/19 6:26 PM 1971PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45deposition,4 leading to hypertrophic scarring or keloid formation (Fig. 45-8). The difference between them is that a hypertrophic scar stops growing 6 months after the injury, whereas a keloid continues to grow, even growing well beyond its borders. Accu-rate approximation and stabilization of the skin edges helps to minimize the amount of collagen deposition required for skin healing. The most important layer to approximate is the dermis because this layer contains the healing elements such as blood supply and cellular elements that create the extracellular matrix necessary for healing. Optimal wound closure involves placing deep dermal |
Surgery_Schwartz_12966 | Surgery_Schwartz | this layer contains the healing elements such as blood supply and cellular elements that create the extracellular matrix necessary for healing. Optimal wound closure involves placing deep dermal sutures followed by superficial sutures that incorpo-rated the upper layers of the dermis and epidermis. Absorbable deep dermal sutures have the advantage of disappearing over time; however, they can promote prolonged inflammation dur-ing this process. Nonabsorbable sutures minimize inflammation and might be indicated in individuals who are particularly prone to scar formation. A step-off between each side of the wound should be avoided because an uneven surface on each side of the wound can cause a shadow that accentuates the presence of the scar. Stability between the two wound edges is important because motion between the two sides of the wound prolongs the inflammatory phase of healing and requires additional col-lagen to be deposited. The timing of suture removal depends on the type of | Surgery_Schwartz. this layer contains the healing elements such as blood supply and cellular elements that create the extracellular matrix necessary for healing. Optimal wound closure involves placing deep dermal sutures followed by superficial sutures that incorpo-rated the upper layers of the dermis and epidermis. Absorbable deep dermal sutures have the advantage of disappearing over time; however, they can promote prolonged inflammation dur-ing this process. Nonabsorbable sutures minimize inflammation and might be indicated in individuals who are particularly prone to scar formation. A step-off between each side of the wound should be avoided because an uneven surface on each side of the wound can cause a shadow that accentuates the presence of the scar. Stability between the two wound edges is important because motion between the two sides of the wound prolongs the inflammatory phase of healing and requires additional col-lagen to be deposited. The timing of suture removal depends on the type of |
Surgery_Schwartz_12967 | Surgery_Schwartz | because motion between the two sides of the wound prolongs the inflammatory phase of healing and requires additional col-lagen to be deposited. The timing of suture removal depends on the type of suture placed in the superficial closure. Sutures placed at the surface that go deep into the dermis can leave addi-tional scarring at the entry and exit points of the suture mate-rial in addition to the incisional scar. Sutures like this should be removed within the first week. If the superficial sutures are placed more shallowly in the dermis, there is a reduced tendency to form additional scarring. A subcuticular suture may be used instead of simple sutures. This type of technique avoids the risk of additional scarring along the wound edge; however, it can be more difficult to accurately reapproximate the skin edges with-out a step-off between the two sides.Wound HealingIn the United States, nonhealing wounds affect about 3 to 6 mil-lion people, with persons 65 years and older accounting | Surgery_Schwartz. because motion between the two sides of the wound prolongs the inflammatory phase of healing and requires additional col-lagen to be deposited. The timing of suture removal depends on the type of suture placed in the superficial closure. Sutures placed at the surface that go deep into the dermis can leave addi-tional scarring at the entry and exit points of the suture mate-rial in addition to the incisional scar. Sutures like this should be removed within the first week. If the superficial sutures are placed more shallowly in the dermis, there is a reduced tendency to form additional scarring. A subcuticular suture may be used instead of simple sutures. This type of technique avoids the risk of additional scarring along the wound edge; however, it can be more difficult to accurately reapproximate the skin edges with-out a step-off between the two sides.Wound HealingIn the United States, nonhealing wounds affect about 3 to 6 mil-lion people, with persons 65 years and older accounting |
Surgery_Schwartz_12968 | Surgery_Schwartz | the skin edges with-out a step-off between the two sides.Wound HealingIn the United States, nonhealing wounds affect about 3 to 6 mil-lion people, with persons 65 years and older accounting for 85% of these events. The annual cost of this problem is estimated to be as high as $25 billion for hospital admissions, antibiotics, and local wound care.3Normal wound healing is achieved through four highly choreographed, overlapping biophysiologic phases: hemostasis, inflammation, proliferation, and tissue remodeling or resolu-tion. Each phase initiates a cascading set of processes critical to the desired result of a healed wound.1Figure 45-8. Hypertrophic scar (left) and keloid (right).Figure 45-9. Phases of wound healing.Hypertrophic ScarKeloidBlood clotBlood vesselScabFibroblastFibroblastsproliferatingFreshlyhealedepidermisFreshlyhealeddermisMacrophageSubcutaneousfatBleedingInflammatoryProliferativeRemodelingSeveral factors impede wound healing and need to be understood so that they can be | Surgery_Schwartz. the skin edges with-out a step-off between the two sides.Wound HealingIn the United States, nonhealing wounds affect about 3 to 6 mil-lion people, with persons 65 years and older accounting for 85% of these events. The annual cost of this problem is estimated to be as high as $25 billion for hospital admissions, antibiotics, and local wound care.3Normal wound healing is achieved through four highly choreographed, overlapping biophysiologic phases: hemostasis, inflammation, proliferation, and tissue remodeling or resolu-tion. Each phase initiates a cascading set of processes critical to the desired result of a healed wound.1Figure 45-8. Hypertrophic scar (left) and keloid (right).Figure 45-9. Phases of wound healing.Hypertrophic ScarKeloidBlood clotBlood vesselScabFibroblastFibroblastsproliferatingFreshlyhealedepidermisFreshlyhealeddermisMacrophageSubcutaneousfatBleedingInflammatoryProliferativeRemodelingSeveral factors impede wound healing and need to be understood so that they can be |
Surgery_Schwartz_12969 | Surgery_Schwartz | factors impede wound healing and need to be understood so that they can be mitigated. Successful mitiga-tion of these adverse factors requires precise, least-traumatic surgical technique that incorporates new methods of prevention and treatment of infection and an understanding of the role of microbial behavior, including the formation of biofilm. Because chronic diseases such as diabetes, vascular insufficiency, and obesity are on the rise, there must be a better understanding of chronic versus acute wounds and how comorbid conditions affect wound healing. Lastly, the impact of age, gender, and nutrition becomes more important as the population of aging patients increases.Phases of Wound HealingThere are different processes that characterize healing in sev-eral types of tissue, such as skin, muscle, or bone, and there is a strong underlying mechanism that is best understood in terms of a simple skin injury. The process of wound healing is com-prised of four integrated processes that | Surgery_Schwartz. factors impede wound healing and need to be understood so that they can be mitigated. Successful mitiga-tion of these adverse factors requires precise, least-traumatic surgical technique that incorporates new methods of prevention and treatment of infection and an understanding of the role of microbial behavior, including the formation of biofilm. Because chronic diseases such as diabetes, vascular insufficiency, and obesity are on the rise, there must be a better understanding of chronic versus acute wounds and how comorbid conditions affect wound healing. Lastly, the impact of age, gender, and nutrition becomes more important as the population of aging patients increases.Phases of Wound HealingThere are different processes that characterize healing in sev-eral types of tissue, such as skin, muscle, or bone, and there is a strong underlying mechanism that is best understood in terms of a simple skin injury. The process of wound healing is com-prised of four integrated processes that |
Surgery_Schwartz_12970 | Surgery_Schwartz | muscle, or bone, and there is a strong underlying mechanism that is best understood in terms of a simple skin injury. The process of wound healing is com-prised of four integrated processes that overlap: (a) bleeding and hemostasis, (b) inflammation, (c) proliferation, and (d) tissue modeling or resolution (Fig. 45-9).These processes occur in sequence over a 1-year duration, but they also significantly overlap and work in terms of a “con-tinuum of processes” rather than discrete “stop-and-go” phases. As shown in Fig. 45-9, each phase is characterized by several Brunicardi_Ch45_p1967-p2026.indd 197101/03/19 6:26 PM 1972SPECIFIC CONSIDERATIONSPART IIwell-defined processes that are dominated by cellular as well as noncellular elements, such as platelets, macrophages, and cyto-kines, that act in concert.Hemostasis. This phase of healing occurs immediately after tissue injury. The most important cells that play a role in the hemostatic process are platelets that degranulate and result | Surgery_Schwartz. muscle, or bone, and there is a strong underlying mechanism that is best understood in terms of a simple skin injury. The process of wound healing is com-prised of four integrated processes that overlap: (a) bleeding and hemostasis, (b) inflammation, (c) proliferation, and (d) tissue modeling or resolution (Fig. 45-9).These processes occur in sequence over a 1-year duration, but they also significantly overlap and work in terms of a “con-tinuum of processes” rather than discrete “stop-and-go” phases. As shown in Fig. 45-9, each phase is characterized by several Brunicardi_Ch45_p1967-p2026.indd 197101/03/19 6:26 PM 1972SPECIFIC CONSIDERATIONSPART IIwell-defined processes that are dominated by cellular as well as noncellular elements, such as platelets, macrophages, and cyto-kines, that act in concert.Hemostasis. This phase of healing occurs immediately after tissue injury. The most important cells that play a role in the hemostatic process are platelets that degranulate and result |
Surgery_Schwartz_12971 | Surgery_Schwartz | act in concert.Hemostasis. This phase of healing occurs immediately after tissue injury. The most important cells that play a role in the hemostatic process are platelets that degranulate and result in the formation of a clot. The extracellular matrix that supports the tissue framework and otherwise acts as a barrier is now open to the vascular compartment, resulting in the release of several factors into the wound. In addition, the release of proteins— otherwise stored within the extracellular matrix—and the presi-dent cells act as further stimulants that start the hemostatic pro-cess. Inflammatory plasma proteins and leukocytes also migrate into the wound. On the cellular level, the plasma membrane of each platelet contains several receptors for collagen (glycopro-tein 1A and 2A). Once these receptors are activated, glycolated granules holding multiple factors that activate hemostasis and inflammation are disrupted, releasing bioactive factors that stimulate platelet aggregation, | Surgery_Schwartz. act in concert.Hemostasis. This phase of healing occurs immediately after tissue injury. The most important cells that play a role in the hemostatic process are platelets that degranulate and result in the formation of a clot. The extracellular matrix that supports the tissue framework and otherwise acts as a barrier is now open to the vascular compartment, resulting in the release of several factors into the wound. In addition, the release of proteins— otherwise stored within the extracellular matrix—and the presi-dent cells act as further stimulants that start the hemostatic pro-cess. Inflammatory plasma proteins and leukocytes also migrate into the wound. On the cellular level, the plasma membrane of each platelet contains several receptors for collagen (glycopro-tein 1A and 2A). Once these receptors are activated, glycolated granules holding multiple factors that activate hemostasis and inflammation are disrupted, releasing bioactive factors that stimulate platelet aggregation, |
Surgery_Schwartz_12972 | Surgery_Schwartz | these receptors are activated, glycolated granules holding multiple factors that activate hemostasis and inflammation are disrupted, releasing bioactive factors that stimulate platelet aggregation, vasoconstriction, and the subse-quent activation of the clotting cascade. As these initial platelet activation factors are released, there is a subsequent push that influences angiogenesis inflammation. These systemic immune response platelet-derived factors include biologically active proteins, such as PDGF, TGF-β, and VEGF, as well as other cytokines, such as PF4 and CD40L.In addition to the release of these factors, the binding of selected proteins within the already developed fibroblasts and the combination of two elements within the extracellular matrix create a chemotactic gradient that activates cell recruitment, cell migration, and cell differentiation and promotes tissue repair. This has been demonstrated clinically in several instances, including orthopedic surgery, cardiac | Surgery_Schwartz. these receptors are activated, glycolated granules holding multiple factors that activate hemostasis and inflammation are disrupted, releasing bioactive factors that stimulate platelet aggregation, vasoconstriction, and the subse-quent activation of the clotting cascade. As these initial platelet activation factors are released, there is a subsequent push that influences angiogenesis inflammation. These systemic immune response platelet-derived factors include biologically active proteins, such as PDGF, TGF-β, and VEGF, as well as other cytokines, such as PF4 and CD40L.In addition to the release of these factors, the binding of selected proteins within the already developed fibroblasts and the combination of two elements within the extracellular matrix create a chemotactic gradient that activates cell recruitment, cell migration, and cell differentiation and promotes tissue repair. This has been demonstrated clinically in several instances, including orthopedic surgery, cardiac |
Surgery_Schwartz_12973 | Surgery_Schwartz | that activates cell recruitment, cell migration, and cell differentiation and promotes tissue repair. This has been demonstrated clinically in several instances, including orthopedic surgery, cardiac surgery, and certain types of skin repair, where autologous platelet transfusions have shown to accelerate the healing process.The subsequent fate of the platelet plug is determined by the amount of circulating fibrinogen. The vascular system interacts with the sympathetic nervous system by eliciting vasoconstriction from the actions of cytokines, prostaglandins, and catecholamines. There is also an alteration of capillary permeability caused by histaminic responses and the mediation of VEGF, which is released from micelles and the damaged endothelium. This highly interactive process results in decreasing blood loss while simultaneously delivering bioactive proteins and cells into the wound environment that kick start the inflammatory process.Inflammation. This is the second phase of | Surgery_Schwartz. that activates cell recruitment, cell migration, and cell differentiation and promotes tissue repair. This has been demonstrated clinically in several instances, including orthopedic surgery, cardiac surgery, and certain types of skin repair, where autologous platelet transfusions have shown to accelerate the healing process.The subsequent fate of the platelet plug is determined by the amount of circulating fibrinogen. The vascular system interacts with the sympathetic nervous system by eliciting vasoconstriction from the actions of cytokines, prostaglandins, and catecholamines. There is also an alteration of capillary permeability caused by histaminic responses and the mediation of VEGF, which is released from micelles and the damaged endothelium. This highly interactive process results in decreasing blood loss while simultaneously delivering bioactive proteins and cells into the wound environment that kick start the inflammatory process.Inflammation. This is the second phase of |
Surgery_Schwartz_12974 | Surgery_Schwartz | in decreasing blood loss while simultaneously delivering bioactive proteins and cells into the wound environment that kick start the inflammatory process.Inflammation. This is the second phase of wound healing and arguably overlaps the hemostatic face. Polymorphonuclear leu-kocytes (PMNs) and macrophages appear in the wound right after platelets, and their primary role is mainly to act as scav-engers. They clear the wound environment of debris, foreign material, bacteria, dead tissue cells and any other devitalized issues that would otherwise impede the healing process. Both macrophages and PMNs aid in phagocytosis and the secretion of free articles that kill bacteria and reduce the bioburden. Cel-lular migration into the wound is highly controlled by bioactive agents within the wound and within the vascular compart-ment. These include cytokines, integrins, selection, and other collagen-derived substances that act in concert. Through anti-body activation, polymorphonuclear cells also | Surgery_Schwartz. in decreasing blood loss while simultaneously delivering bioactive proteins and cells into the wound environment that kick start the inflammatory process.Inflammation. This is the second phase of wound healing and arguably overlaps the hemostatic face. Polymorphonuclear leu-kocytes (PMNs) and macrophages appear in the wound right after platelets, and their primary role is mainly to act as scav-engers. They clear the wound environment of debris, foreign material, bacteria, dead tissue cells and any other devitalized issues that would otherwise impede the healing process. Both macrophages and PMNs aid in phagocytosis and the secretion of free articles that kill bacteria and reduce the bioburden. Cel-lular migration into the wound is highly controlled by bioactive agents within the wound and within the vascular compart-ment. These include cytokines, integrins, selection, and other collagen-derived substances that act in concert. Through anti-body activation, polymorphonuclear cells also |
Surgery_Schwartz_12975 | Surgery_Schwartz | within the vascular compart-ment. These include cytokines, integrins, selection, and other collagen-derived substances that act in concert. Through anti-body activation, polymorphonuclear cells also interact with the humoral system to facilitate the key functions of cell activation, recruitment, and proliferation, as well as migration from the intravascular compartment to the extracellular matrix. Within 48 hours of tissue injury, PMNs and macrophages are recruited to the wound in very large numbers, heralding the inflamma-tory response. As described in other chapters in this text, macro-phages possess a very large repertoire of functions, all of which are geared towards removing the nonviable elements in the wound and recruiting other cell types into the wound that facili-tate angiogenesis, fibroblast function, and subsequent repair. A summary of various macrophage-related functions is broadly classified into 7 major categories:1. Phagocytosis2. Release of reactive oxygen species | Surgery_Schwartz. within the vascular compart-ment. These include cytokines, integrins, selection, and other collagen-derived substances that act in concert. Through anti-body activation, polymorphonuclear cells also interact with the humoral system to facilitate the key functions of cell activation, recruitment, and proliferation, as well as migration from the intravascular compartment to the extracellular matrix. Within 48 hours of tissue injury, PMNs and macrophages are recruited to the wound in very large numbers, heralding the inflamma-tory response. As described in other chapters in this text, macro-phages possess a very large repertoire of functions, all of which are geared towards removing the nonviable elements in the wound and recruiting other cell types into the wound that facili-tate angiogenesis, fibroblast function, and subsequent repair. A summary of various macrophage-related functions is broadly classified into 7 major categories:1. Phagocytosis2. Release of reactive oxygen species |
Surgery_Schwartz_12976 | Surgery_Schwartz | fibroblast function, and subsequent repair. A summary of various macrophage-related functions is broadly classified into 7 major categories:1. Phagocytosis2. Release of reactive oxygen species that result in cellular kill-ing specifically related towards bacterial lysis3. Release of nitric oxide that is deadly to several otherwise antibody-resistant bacteria4. Cytokine release of interleukins (IL1, IL2, IL4, and IL12)5. Angiogenesis via VEGF that promotes capillary budding6. Recruitment of other cells into the wound that continue the healing process7. Different homeostatic roles of macrophages and Langerhans cells, including wound repair, follicle regeneration, salt bal-ance, and cancer regression and progression in the skinInterestingly, the inflammatory phase determines the dif-ference between chronic and acute wounds. Uncomplicated wounds heal within 4 to 6 weeks. If they continue to remain nonhealing beyond this time, they are termed chronic. Several local and systemic factors | Surgery_Schwartz. fibroblast function, and subsequent repair. A summary of various macrophage-related functions is broadly classified into 7 major categories:1. Phagocytosis2. Release of reactive oxygen species that result in cellular kill-ing specifically related towards bacterial lysis3. Release of nitric oxide that is deadly to several otherwise antibody-resistant bacteria4. Cytokine release of interleukins (IL1, IL2, IL4, and IL12)5. Angiogenesis via VEGF that promotes capillary budding6. Recruitment of other cells into the wound that continue the healing process7. Different homeostatic roles of macrophages and Langerhans cells, including wound repair, follicle regeneration, salt bal-ance, and cancer regression and progression in the skinInterestingly, the inflammatory phase determines the dif-ference between chronic and acute wounds. Uncomplicated wounds heal within 4 to 6 weeks. If they continue to remain nonhealing beyond this time, they are termed chronic. Several local and systemic factors |
Surgery_Schwartz_12977 | Surgery_Schwartz | between chronic and acute wounds. Uncomplicated wounds heal within 4 to 6 weeks. If they continue to remain nonhealing beyond this time, they are termed chronic. Several local and systemic factors affect the inflammatory phase of wound healing directly. These include pressure, tissue hypoxia, infection, tissue contamination, desiccation, and maceration. Systemic factors include age, stress, and comorbid conditions such as diabetes, vascular insufficiency, immunocompromise, malnourishment, obesity, and smoking. The common thread, however, in all nonhealing chronic wounds is the persistence of proinflammatory conditions. These specific tissue deficits result in a chronic cycle of chronically migrating inflammatory cells (PMNs, macrophages) that scavenge early healing tissue, degrade the newly formed matrix proteins, and then cyclically recover only to restart the inflammatory phase. This cycle leads to a chronically unstable wound that is unable to progress to the next phases of | Surgery_Schwartz. between chronic and acute wounds. Uncomplicated wounds heal within 4 to 6 weeks. If they continue to remain nonhealing beyond this time, they are termed chronic. Several local and systemic factors affect the inflammatory phase of wound healing directly. These include pressure, tissue hypoxia, infection, tissue contamination, desiccation, and maceration. Systemic factors include age, stress, and comorbid conditions such as diabetes, vascular insufficiency, immunocompromise, malnourishment, obesity, and smoking. The common thread, however, in all nonhealing chronic wounds is the persistence of proinflammatory conditions. These specific tissue deficits result in a chronic cycle of chronically migrating inflammatory cells (PMNs, macrophages) that scavenge early healing tissue, degrade the newly formed matrix proteins, and then cyclically recover only to restart the inflammatory phase. This cycle leads to a chronically unstable wound that is unable to progress to the next phases of |
Surgery_Schwartz_12978 | Surgery_Schwartz | the newly formed matrix proteins, and then cyclically recover only to restart the inflammatory phase. This cycle leads to a chronically unstable wound that is unable to progress to the next phases of healing: cell proliferation, tissue remodeling, and resolution.Biofilm One of the recent discoveries in the area of biofilm is an important microbial factor that impedes healing by affecting inflammatory processes in the wound-healing continuum. Biofilm comprises a colony of microorganisms enveloped with a matrix of extracellular polymers also known as extracellular polymeric substance (EPS) (Fig. 45-10). EPS affects chronic and acute dermal wounds. Its life cycle and effects on the bacterial colonies it protects are shown in Figs. 45-11 and 45-12. These include antibiotic resistance; latency (the ability to enter into latent states during inhospitable conditions); increasing species diversity; and quorum sensing (bacteria in the biofilm engage in a type of decision-making process in | Surgery_Schwartz. the newly formed matrix proteins, and then cyclically recover only to restart the inflammatory phase. This cycle leads to a chronically unstable wound that is unable to progress to the next phases of healing: cell proliferation, tissue remodeling, and resolution.Biofilm One of the recent discoveries in the area of biofilm is an important microbial factor that impedes healing by affecting inflammatory processes in the wound-healing continuum. Biofilm comprises a colony of microorganisms enveloped with a matrix of extracellular polymers also known as extracellular polymeric substance (EPS) (Fig. 45-10). EPS affects chronic and acute dermal wounds. Its life cycle and effects on the bacterial colonies it protects are shown in Figs. 45-11 and 45-12. These include antibiotic resistance; latency (the ability to enter into latent states during inhospitable conditions); increasing species diversity; and quorum sensing (bacteria in the biofilm engage in a type of decision-making process in |
Surgery_Schwartz_12979 | Surgery_Schwartz | (the ability to enter into latent states during inhospitable conditions); increasing species diversity; and quorum sensing (bacteria in the biofilm engage in a type of decision-making process in which behavior is coordinated through a “chemical” vocabulary).Proliferation. This phase is arguably the first step towards restoration of tissue continuity. It is characterized by the pro-duction of extracellular matrix by the fibroblast, the most prominent cell type in the proliferative phase. Fibroblasts are Brunicardi_Ch45_p1967-p2026.indd 197201/03/19 6:26 PM 1973PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-10. Slough that also comprises biofilm.Figure 45-11. The lifecycle of biofilm.Figure 45-12. Biofilm is a barrier to wound healing.V. choleraebiofilmPhytoplanktonMetabolicallyactive cellMetabolicallyquiescent cellPlanktonic V. choleraeMSHA pilusAquatic environmentFlagellumDetritusZooplanktonSmall intestineTCPSheddingIngestionReleaseTCPbundlingMucusHuman hostStoolthe | Surgery_Schwartz. (the ability to enter into latent states during inhospitable conditions); increasing species diversity; and quorum sensing (bacteria in the biofilm engage in a type of decision-making process in which behavior is coordinated through a “chemical” vocabulary).Proliferation. This phase is arguably the first step towards restoration of tissue continuity. It is characterized by the pro-duction of extracellular matrix by the fibroblast, the most prominent cell type in the proliferative phase. Fibroblasts are Brunicardi_Ch45_p1967-p2026.indd 197201/03/19 6:26 PM 1973PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 45Figure 45-10. Slough that also comprises biofilm.Figure 45-11. The lifecycle of biofilm.Figure 45-12. Biofilm is a barrier to wound healing.V. choleraebiofilmPhytoplanktonMetabolicallyactive cellMetabolicallyquiescent cellPlanktonic V. choleraeMSHA pilusAquatic environmentFlagellumDetritusZooplanktonSmall intestineTCPSheddingIngestionReleaseTCPbundlingMucusHuman hostStoolthe |
Surgery_Schwartz_12980 | Surgery_Schwartz | cellMetabolicallyquiescent cellPlanktonic V. choleraeMSHA pilusAquatic environmentFlagellumDetritusZooplanktonSmall intestineTCPSheddingIngestionReleaseTCPbundlingMucusHuman hostStoolthe architects of wound healing and appear in the wound right at the end of the inflammatory phase. Collectively, fibroblasts support several major functions that lead to tissue repair, includ-ing the formation of collagen and the structural creation of the extracellular matrix. The formation of fibrin and fibronectin that is precipitated from the blood clot results in the formation of a provisional extracellular matrix that serves as a scaffold. Typically, this matrix can be compared to the framework of a building without any walls or windows. The protein scaf-fold serves as a solid framework that subsequently hosts cells including human macrophages and fibroblasts. Simultane-ous VEGF-derived angiogenesis promotes the formation of small vascular loops, known as capillary buds, that proliferate within | Surgery_Schwartz. cellMetabolicallyquiescent cellPlanktonic V. choleraeMSHA pilusAquatic environmentFlagellumDetritusZooplanktonSmall intestineTCPSheddingIngestionReleaseTCPbundlingMucusHuman hostStoolthe architects of wound healing and appear in the wound right at the end of the inflammatory phase. Collectively, fibroblasts support several major functions that lead to tissue repair, includ-ing the formation of collagen and the structural creation of the extracellular matrix. The formation of fibrin and fibronectin that is precipitated from the blood clot results in the formation of a provisional extracellular matrix that serves as a scaffold. Typically, this matrix can be compared to the framework of a building without any walls or windows. The protein scaf-fold serves as a solid framework that subsequently hosts cells including human macrophages and fibroblasts. Simultane-ous VEGF-derived angiogenesis promotes the formation of small vascular loops, known as capillary buds, that proliferate within |
Surgery_Schwartz_12981 | Surgery_Schwartz | hosts cells including human macrophages and fibroblasts. Simultane-ous VEGF-derived angiogenesis promotes the formation of small vascular loops, known as capillary buds, that proliferate within the fibroblast matrix. Paradoxically, the major activat-ing factor responsible for the formation of capillary buds is low oxygen tension. Poor oxygenation of the tissues increases Brunicardi_Ch45_p1967-p2026.indd 197301/03/19 6:26 PM 1974SPECIFIC CONSIDERATIONSPART IIthe expression of hypoxia inducible factor (HIF) by endothe-lial cells. Specific DNA sequences of cells that regulate angio-genesis are turned on by HIF. This paradoxical negative loop is directly related to a low oxygen tension within the tissues. Subsequent release of the epidermal growth factor EGF and the transforming growth factor TGF-α by several cell types, including macrophages, platelets, and keratinocytes, strengthen the newly formed extracellular matrix. Once a robust scaffold is built, the epidermal cells from the | Surgery_Schwartz. hosts cells including human macrophages and fibroblasts. Simultane-ous VEGF-derived angiogenesis promotes the formation of small vascular loops, known as capillary buds, that proliferate within the fibroblast matrix. Paradoxically, the major activat-ing factor responsible for the formation of capillary buds is low oxygen tension. Poor oxygenation of the tissues increases Brunicardi_Ch45_p1967-p2026.indd 197301/03/19 6:26 PM 1974SPECIFIC CONSIDERATIONSPART IIthe expression of hypoxia inducible factor (HIF) by endothe-lial cells. Specific DNA sequences of cells that regulate angio-genesis are turned on by HIF. This paradoxical negative loop is directly related to a low oxygen tension within the tissues. Subsequent release of the epidermal growth factor EGF and the transforming growth factor TGF-α by several cell types, including macrophages, platelets, and keratinocytes, strengthen the newly formed extracellular matrix. Once a robust scaffold is built, the epidermal cells from the |
Surgery_Schwartz_12982 | Surgery_Schwartz | TGF-α by several cell types, including macrophages, platelets, and keratinocytes, strengthen the newly formed extracellular matrix. Once a robust scaffold is built, the epidermal cells from the edges of the wound on all sides migrate towards the center of the wound. This process is facilitated by several factors, including angiogenesis, neovas-cularization, and the release of fibroblast growth factor TGF-β and epidermal growth factor. The formation of the extracellular matrix is the key process that leads to subsequent reepithelial-ization. The extracellular matrix is primarily made of collagen. The different types of collagen that occur more predominantly in different types of tissues characterize the type of healing that occurs. Specifically, type I is present in scar tissues. After the formation of collagen, the fibers are now attached to form a provisional fibrin matrix. After a variety of complicated signal-ing that includes the transcription and processing of collagen messenger | Surgery_Schwartz. TGF-α by several cell types, including macrophages, platelets, and keratinocytes, strengthen the newly formed extracellular matrix. Once a robust scaffold is built, the epidermal cells from the edges of the wound on all sides migrate towards the center of the wound. This process is facilitated by several factors, including angiogenesis, neovas-cularization, and the release of fibroblast growth factor TGF-β and epidermal growth factor. The formation of the extracellular matrix is the key process that leads to subsequent reepithelial-ization. The extracellular matrix is primarily made of collagen. The different types of collagen that occur more predominantly in different types of tissues characterize the type of healing that occurs. Specifically, type I is present in scar tissues. After the formation of collagen, the fibers are now attached to form a provisional fibrin matrix. After a variety of complicated signal-ing that includes the transcription and processing of collagen messenger |
Surgery_Schwartz_12983 | Surgery_Schwartz | formation of collagen, the fibers are now attached to form a provisional fibrin matrix. After a variety of complicated signal-ing that includes the transcription and processing of collagen messenger RNA, the collagen gets attached to hydroxylation of protein and lysine. The hydroxyproline in the collagen is responsible for the stable helical confirmation that is critical for the formation of a robust strong scar. It then transforms itself into a classical triple helical structure that is subsequently modified through glycosylation. It is important to realize that increased collagen stability is directly related to the degree of hydroxylation of the collagen and that fragile forms of colla-gen (which result in a fragile scar) are largely due to increases in nonhydroxylated collagen forms. Certain diseases including scurvy (vitamin C deficiency) or other diseases that are pre-dominantly anaerobic in their nature can cause the formation of week nonhydroxylated collagen, which is fragile | Surgery_Schwartz. formation of collagen, the fibers are now attached to form a provisional fibrin matrix. After a variety of complicated signal-ing that includes the transcription and processing of collagen messenger RNA, the collagen gets attached to hydroxylation of protein and lysine. The hydroxyproline in the collagen is responsible for the stable helical confirmation that is critical for the formation of a robust strong scar. It then transforms itself into a classical triple helical structure that is subsequently modified through glycosylation. It is important to realize that increased collagen stability is directly related to the degree of hydroxylation of the collagen and that fragile forms of colla-gen (which result in a fragile scar) are largely due to increases in nonhydroxylated collagen forms. Certain diseases including scurvy (vitamin C deficiency) or other diseases that are pre-dominantly anaerobic in their nature can cause the formation of week nonhydroxylated collagen, which is fragile |
Surgery_Schwartz_12984 | Surgery_Schwartz | Certain diseases including scurvy (vitamin C deficiency) or other diseases that are pre-dominantly anaerobic in their nature can cause the formation of week nonhydroxylated collagen, which is fragile and can easily undergo denaturation and lysis.The next step is the cleavage of the procollagen N and C terminal peptides. A very important extracellular enzyme called lysyl oxidase is responsible for the strengthening of collagen by the formation of strong, stable cross-linkages. Microscopic examination of stable mature scars reveals that strong cross-linkages present in the intramolecular and the intermolecular compartments directly correlate with strength and stability. Epi-dermal cells migrate over the scaffold, and after the epithelial bridge is completed, enzymes are released to dissolve the attach-ment at the base of the overlying scab that falls off.Contraction is one of the key end phases of proliferation. Typically, contraction starts approximately 7 days from tissue injury, when | Surgery_Schwartz. Certain diseases including scurvy (vitamin C deficiency) or other diseases that are pre-dominantly anaerobic in their nature can cause the formation of week nonhydroxylated collagen, which is fragile and can easily undergo denaturation and lysis.The next step is the cleavage of the procollagen N and C terminal peptides. A very important extracellular enzyme called lysyl oxidase is responsible for the strengthening of collagen by the formation of strong, stable cross-linkages. Microscopic examination of stable mature scars reveals that strong cross-linkages present in the intramolecular and the intermolecular compartments directly correlate with strength and stability. Epi-dermal cells migrate over the scaffold, and after the epithelial bridge is completed, enzymes are released to dissolve the attach-ment at the base of the overlying scab that falls off.Contraction is one of the key end phases of proliferation. Typically, contraction starts approximately 7 days from tissue injury, when |
Surgery_Schwartz_12985 | Surgery_Schwartz | the attach-ment at the base of the overlying scab that falls off.Contraction is one of the key end phases of proliferation. Typically, contraction starts approximately 7 days from tissue injury, when the fibroblasts differentiate into myofibroblasts. Myofibroblasts are similar to smooth muscle cells, have the same amount of actin (responsible for mobility), and are responsible for contraction it peaks at around 10 days post injury but can continue for several weeks. Myofibroblasts attach to the extra cellular matrix (ECM) at the wound edges and to each other as well as to the wound edges via desmosomes and the fibronexus, through which actin in the myofibroblast is linked across the cell membrane to molecules in the extracellular matrix like fibro-nectin and collagen. This in turn facilitates the myofibroblasts to pull the ECM when they contract, thus reducing the wound size. Wounds contract at the rate of 0.75 mm to 1 mm daily. The formation of a strong, contracted, cross-linked | Surgery_Schwartz. the attach-ment at the base of the overlying scab that falls off.Contraction is one of the key end phases of proliferation. Typically, contraction starts approximately 7 days from tissue injury, when the fibroblasts differentiate into myofibroblasts. Myofibroblasts are similar to smooth muscle cells, have the same amount of actin (responsible for mobility), and are responsible for contraction it peaks at around 10 days post injury but can continue for several weeks. Myofibroblasts attach to the extra cellular matrix (ECM) at the wound edges and to each other as well as to the wound edges via desmosomes and the fibronexus, through which actin in the myofibroblast is linked across the cell membrane to molecules in the extracellular matrix like fibro-nectin and collagen. This in turn facilitates the myofibroblasts to pull the ECM when they contract, thus reducing the wound size. Wounds contract at the rate of 0.75 mm to 1 mm daily. The formation of a strong, contracted, cross-linked |
Surgery_Schwartz_12986 | Surgery_Schwartz | the myofibroblasts to pull the ECM when they contract, thus reducing the wound size. Wounds contract at the rate of 0.75 mm to 1 mm daily. The formation of a strong, contracted, cross-linked collagen scar with reepithelization heralds the end of the proliferative phase. Contraction usually does not occur symmetrically; instead, most wounds have an “axis of contraction” that allows for greater organization and alignment of cells with collagen.Remodeling/Maturation. The remodeling phase is also termed the maturation phase. It is primarily characterized by the remodeling of collagen through a balance between collagen for-mation and collagen lysis that results in the formation of a strong scar. Biochemically, the collagen is remodeled from type III to type I and is also accompanied by complete reepithelialization of the wound. The lysis of collagen is mediated by collagenases that are secreted by various cells—fibroblasts, neutrophils, and macrophages—each of which can cleave the collagen | Surgery_Schwartz. the myofibroblasts to pull the ECM when they contract, thus reducing the wound size. Wounds contract at the rate of 0.75 mm to 1 mm daily. The formation of a strong, contracted, cross-linked collagen scar with reepithelization heralds the end of the proliferative phase. Contraction usually does not occur symmetrically; instead, most wounds have an “axis of contraction” that allows for greater organization and alignment of cells with collagen.Remodeling/Maturation. The remodeling phase is also termed the maturation phase. It is primarily characterized by the remodeling of collagen through a balance between collagen for-mation and collagen lysis that results in the formation of a strong scar. Biochemically, the collagen is remodeled from type III to type I and is also accompanied by complete reepithelialization of the wound. The lysis of collagen is mediated by collagenases that are secreted by various cells—fibroblasts, neutrophils, and macrophages—each of which can cleave the collagen |
Surgery_Schwartz_12987 | Surgery_Schwartz | reepithelialization of the wound. The lysis of collagen is mediated by collagenases that are secreted by various cells—fibroblasts, neutrophils, and macrophages—each of which can cleave the collagen molecule at different but specific locations on all three chains and break it down to characteristic three-quarter and one-quarter pieces. These collagen fragments undergo further denaturation and digestion by other proteases. There is significant remodeling of the collagen during this process. It is aligned along tension lines, and significant reabsorption of water from the collagen fibers result in a denser alignment and stronger cross-linking. The remodeling phase establishes a new equilibrium with the forma-tion of an organized scar. Several molecules, including TGF-β, which induces intracellular signaling of SMAD proteins, play an important role in the remodeling phase. Using SM 80 knockout mice and transgenic animals, a critical role of the SMAD path-way in the formation of scar has | Surgery_Schwartz. reepithelialization of the wound. The lysis of collagen is mediated by collagenases that are secreted by various cells—fibroblasts, neutrophils, and macrophages—each of which can cleave the collagen molecule at different but specific locations on all three chains and break it down to characteristic three-quarter and one-quarter pieces. These collagen fragments undergo further denaturation and digestion by other proteases. There is significant remodeling of the collagen during this process. It is aligned along tension lines, and significant reabsorption of water from the collagen fibers result in a denser alignment and stronger cross-linking. The remodeling phase establishes a new equilibrium with the forma-tion of an organized scar. Several molecules, including TGF-β, which induces intracellular signaling of SMAD proteins, play an important role in the remodeling phase. Using SM 80 knockout mice and transgenic animals, a critical role of the SMAD path-way in the formation of scar has |
Surgery_Schwartz_12988 | Surgery_Schwartz | signaling of SMAD proteins, play an important role in the remodeling phase. Using SM 80 knockout mice and transgenic animals, a critical role of the SMAD path-way in the formation of scar has been delineated. This process is also facilitated by apoptosis and programmatic cell death, which helps to former a thinner scar that is stronger and more cosmeti-cally appealing. This phase begins 3 weeks after the injury and continues for over 1 year. One must realize that despite the best cross-linking, scar tissue is weaker than injured skin and regains only 80% of its uninjured tensile strength. As it matures fur-ther, it becomes less red and less vascular because the reduced biologic activity within the scar renders the vascular capillaries redundant and they apoptose.RECONSTRUCTIVE SURGERYReconstructive surgery restores normal anatomy and function using plastic surgery methods of tissue repair, rearrangement, and replacement. Tissues can be missing or damaged as a con-sequence of trauma, | Surgery_Schwartz. signaling of SMAD proteins, play an important role in the remodeling phase. Using SM 80 knockout mice and transgenic animals, a critical role of the SMAD path-way in the formation of scar has been delineated. This process is also facilitated by apoptosis and programmatic cell death, which helps to former a thinner scar that is stronger and more cosmeti-cally appealing. This phase begins 3 weeks after the injury and continues for over 1 year. One must realize that despite the best cross-linking, scar tissue is weaker than injured skin and regains only 80% of its uninjured tensile strength. As it matures fur-ther, it becomes less red and less vascular because the reduced biologic activity within the scar renders the vascular capillaries redundant and they apoptose.RECONSTRUCTIVE SURGERYReconstructive surgery restores normal anatomy and function using plastic surgery methods of tissue repair, rearrangement, and replacement. Tissues can be missing or damaged as a con-sequence of trauma, |
Surgery_Schwartz_12989 | Surgery_Schwartz | surgery restores normal anatomy and function using plastic surgery methods of tissue repair, rearrangement, and replacement. Tissues can be missing or damaged as a con-sequence of trauma, cancer, degeneration, congenital abnor-malities, and aging. The primary adverse consequence of lost or impaired tissue is functional disability, which includes physical, psychologic, or social dysfunction. The clinical objective is to reestablish normal anatomy, function, and appearance in order to restore the patient as closely as possible to normal health. The most useful techniques transfer and modify tissues in the form of tissue grafts and surgical flaps.RECONSTRUCTIVE STRATEGIES AND METHODSThe main aim of wound healing is to achieve a closed wound. Ordinarily, wounds heal via three main mechanisms:1. Primary intention: This type of healing occurs in a clean wound without any apparent tissue loss. Mostly seen in surgical incisions that have been approximated (primary closure), healing by primary | Surgery_Schwartz. surgery restores normal anatomy and function using plastic surgery methods of tissue repair, rearrangement, and replacement. Tissues can be missing or damaged as a con-sequence of trauma, cancer, degeneration, congenital abnor-malities, and aging. The primary adverse consequence of lost or impaired tissue is functional disability, which includes physical, psychologic, or social dysfunction. The clinical objective is to reestablish normal anatomy, function, and appearance in order to restore the patient as closely as possible to normal health. The most useful techniques transfer and modify tissues in the form of tissue grafts and surgical flaps.RECONSTRUCTIVE STRATEGIES AND METHODSThe main aim of wound healing is to achieve a closed wound. Ordinarily, wounds heal via three main mechanisms:1. Primary intention: This type of healing occurs in a clean wound without any apparent tissue loss. Mostly seen in surgical incisions that have been approximated (primary closure), healing by primary |
Surgery_Schwartz_12990 | Surgery_Schwartz | intention: This type of healing occurs in a clean wound without any apparent tissue loss. Mostly seen in surgical incisions that have been approximated (primary closure), healing by primary intention can only be imple-mented when the closure of the wound is precise and there is minimal disruption to the local tissue or the epithelial basement membrane. Typically, this wound seals off within 24 hours. Healing is faster than healing by secondary inten-tion, and there is the least amount of scarring.2Brunicardi_Ch45_p1967-p2026.indd 197401/03/19 6:26 PM 1975PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 452. Secondary intention: Tissue loss following major trauma results in the formation of granulation tissue, which results in a broader scar (see earlier section, “Phases of Wound Healing”).3. Tertiary intention (delayed primary closure or second-ary suture): The wound is initially cleaned, debrided, and observed, typically 4 or 5 days before closure. Examples of this type of healing | Surgery_Schwartz. intention: This type of healing occurs in a clean wound without any apparent tissue loss. Mostly seen in surgical incisions that have been approximated (primary closure), healing by primary intention can only be imple-mented when the closure of the wound is precise and there is minimal disruption to the local tissue or the epithelial basement membrane. Typically, this wound seals off within 24 hours. Healing is faster than healing by secondary inten-tion, and there is the least amount of scarring.2Brunicardi_Ch45_p1967-p2026.indd 197401/03/19 6:26 PM 1975PLASTIC AND RECONSTRUCTIVE SURGERYCHAPTER 452. Secondary intention: Tissue loss following major trauma results in the formation of granulation tissue, which results in a broader scar (see earlier section, “Phases of Wound Healing”).3. Tertiary intention (delayed primary closure or second-ary suture): The wound is initially cleaned, debrided, and observed, typically 4 or 5 days before closure. Examples of this type of healing |
Surgery_Schwartz_12991 | Surgery_Schwartz | intention (delayed primary closure or second-ary suture): The wound is initially cleaned, debrided, and observed, typically 4 or 5 days before closure. Examples of this type of healing include healing through the use of tissue grafts, including skin grafts and substitutes.Skin Grafts and Skin SubstitutesSkin grafting methods date back millennia to ancient India, where they were used to resurface nasal defects. They were introduced in the modern era by Guiseppe Baronio, an Italian physician who studied skin grafting techniques in sheep and published his work entitled Degli Innesti Animali (On Grafting in Animals) in 1804.4It is important to know the basic anatomic structure of skin in order to understand the principles of skin grafting. Skin is comprised of the epidermis, the dermis, specialized sensory nerve endings, and various skin appendages that lubricate and protect the skin as well as contribute to functions such as ther-moregulation. The epidermis is a layer of cells that | Surgery_Schwartz. intention (delayed primary closure or second-ary suture): The wound is initially cleaned, debrided, and observed, typically 4 or 5 days before closure. Examples of this type of healing include healing through the use of tissue grafts, including skin grafts and substitutes.Skin Grafts and Skin SubstitutesSkin grafting methods date back millennia to ancient India, where they were used to resurface nasal defects. They were introduced in the modern era by Guiseppe Baronio, an Italian physician who studied skin grafting techniques in sheep and published his work entitled Degli Innesti Animali (On Grafting in Animals) in 1804.4It is important to know the basic anatomic structure of skin in order to understand the principles of skin grafting. Skin is comprised of the epidermis, the dermis, specialized sensory nerve endings, and various skin appendages that lubricate and protect the skin as well as contribute to functions such as ther-moregulation. The epidermis is a layer of cells that |
Surgery_Schwartz_12992 | Surgery_Schwartz | specialized sensory nerve endings, and various skin appendages that lubricate and protect the skin as well as contribute to functions such as ther-moregulation. The epidermis is a layer of cells that affords pri-mary barrier function. It begins with a layer of cells called the basal layer. These are cuboidal-shaped cells that multiply and differentiate into flattened, keratinized squamous cells, which progressively migrate from the basal layers until they are finally released from the surface in a process known as desquamation. The junction between the dermis and the epidermis is composed of projections from the dermis into the epidermis, which are called dermal papillae. This feature secures the epidermis to the dermis by resisting sheer forces transmitted from the skin surface, helping to prevent separation of the epidermis from the dermis. The dermis contains sebaceous glands, whereas sweat glands and hair follicles are actually located below the dermis in the subcutaneous tissue | Surgery_Schwartz. specialized sensory nerve endings, and various skin appendages that lubricate and protect the skin as well as contribute to functions such as ther-moregulation. The epidermis is a layer of cells that affords pri-mary barrier function. It begins with a layer of cells called the basal layer. These are cuboidal-shaped cells that multiply and differentiate into flattened, keratinized squamous cells, which progressively migrate from the basal layers until they are finally released from the surface in a process known as desquamation. The junction between the dermis and the epidermis is composed of projections from the dermis into the epidermis, which are called dermal papillae. This feature secures the epidermis to the dermis by resisting sheer forces transmitted from the skin surface, helping to prevent separation of the epidermis from the dermis. The dermis contains sebaceous glands, whereas sweat glands and hair follicles are actually located below the dermis in the subcutaneous tissue |
Surgery_Schwartz_12993 | Surgery_Schwartz | to prevent separation of the epidermis from the dermis. The dermis contains sebaceous glands, whereas sweat glands and hair follicles are actually located below the dermis in the subcutaneous tissue and traverse the dermis and epithe-lium to reach the body surface. The dermal thickness and con-centration of skin appendages vary widely from one location to another on the body. The blood supply to the skin occurs in a variety of patterns that form the basis for transferring tissue-containing skin, which will be discussed later in this chapter. Regardless of the pattern, there is a network of vessels just below the dermis called the subdermal plexus that supplies the skin immediately above and is important in thermoregulation. Finally, terminal vessels and capillaries fill the dermis and pen-etrate the dermal papillae to perfuse the cellular elements of the dermis and epidermis.Skin grafting methods include split-thickness skin grafts (STSG), full-thickness skin grafts (FTSG), and | Surgery_Schwartz. to prevent separation of the epidermis from the dermis. The dermis contains sebaceous glands, whereas sweat glands and hair follicles are actually located below the dermis in the subcutaneous tissue and traverse the dermis and epithe-lium to reach the body surface. The dermal thickness and con-centration of skin appendages vary widely from one location to another on the body. The blood supply to the skin occurs in a variety of patterns that form the basis for transferring tissue-containing skin, which will be discussed later in this chapter. Regardless of the pattern, there is a network of vessels just below the dermis called the subdermal plexus that supplies the skin immediately above and is important in thermoregulation. Finally, terminal vessels and capillaries fill the dermis and pen-etrate the dermal papillae to perfuse the cellular elements of the dermis and epidermis.Skin grafting methods include split-thickness skin grafts (STSG), full-thickness skin grafts (FTSG), and |
Surgery_Schwartz_12994 | Surgery_Schwartz | pen-etrate the dermal papillae to perfuse the cellular elements of the dermis and epidermis.Skin grafting methods include split-thickness skin grafts (STSG), full-thickness skin grafts (FTSG), and composite tissue grafts. Each has its advantages and disadvantages, and select-ing the best technique for a given circumstance depends on the reconstructive requirements, the quality of the recipient wound bed, and the availability of donor site tissue.Split-Thickness Grafts. An STSG is the simplest method of tissue transfer. The name is derived from how these grafts are harvested by cutting through (i.e., splitting) the dermis at various levels. Thin STSGs are harvested through the superficial levels of the dermis. Thick grafts are harvested through deeper layers and include a larger amount of dermal tissue. The impor-tant characteristics of STSGs are determined by the thickness of dermis present in the graft. Thin grafts undergo less primary contraction after harvest because they contain | Surgery_Schwartz. pen-etrate the dermal papillae to perfuse the cellular elements of the dermis and epidermis.Skin grafting methods include split-thickness skin grafts (STSG), full-thickness skin grafts (FTSG), and composite tissue grafts. Each has its advantages and disadvantages, and select-ing the best technique for a given circumstance depends on the reconstructive requirements, the quality of the recipient wound bed, and the availability of donor site tissue.Split-Thickness Grafts. An STSG is the simplest method of tissue transfer. The name is derived from how these grafts are harvested by cutting through (i.e., splitting) the dermis at various levels. Thin STSGs are harvested through the superficial levels of the dermis. Thick grafts are harvested through deeper layers and include a larger amount of dermal tissue. The impor-tant characteristics of STSGs are determined by the thickness of dermis present in the graft. Thin grafts undergo less primary contraction after harvest because they contain |
Surgery_Schwartz_12995 | Surgery_Schwartz | dermal tissue. The impor-tant characteristics of STSGs are determined by the thickness of dermis present in the graft. Thin grafts undergo less primary contraction after harvest because they contain fewer elements of the dermal extracellular matrix such as elastic fibers. Thick grafts undergo greater amounts of primary contraction. This is important to remember when harvesting the graft because it is necessary to obtain sufficient tissue in order to restore the defect. On the other hand, thin grafts allow the wound to undergo a greater amount of contraction in a process traditionally referred to secondary contraction of the graft. This becomes important if the wound is adjacent to a mobile structure such as the oral commissure, which might be distorted as healing progresses. Thin grafts also have improved chances of complete engraft-ment, or “taking,” as they contain mostly epidermis, which has low metabolic demands, in contrast to thicker grafts that contain more dermis with greater | Surgery_Schwartz. dermal tissue. The impor-tant characteristics of STSGs are determined by the thickness of dermis present in the graft. Thin grafts undergo less primary contraction after harvest because they contain fewer elements of the dermal extracellular matrix such as elastic fibers. Thick grafts undergo greater amounts of primary contraction. This is important to remember when harvesting the graft because it is necessary to obtain sufficient tissue in order to restore the defect. On the other hand, thin grafts allow the wound to undergo a greater amount of contraction in a process traditionally referred to secondary contraction of the graft. This becomes important if the wound is adjacent to a mobile structure such as the oral commissure, which might be distorted as healing progresses. Thin grafts also have improved chances of complete engraft-ment, or “taking,” as they contain mostly epidermis, which has low metabolic demands, in contrast to thicker grafts that contain more dermis with greater |
Surgery_Schwartz_12996 | Surgery_Schwartz | have improved chances of complete engraft-ment, or “taking,” as they contain mostly epidermis, which has low metabolic demands, in contrast to thicker grafts that contain more dermis with greater metabolic needs.A variety of techniques have been described to maximize the surface area that can be covered by harvested skin amount while minimizing the size of the donor site.5 One approach is to process the harvested skin into micrografts using devices spe-cially designed for this purpose in the operating room. Another method is fractional skin harvesting, which involves harvesting a large number of full-thickness skin tissue columns that are then seeded onto the wound surface. The traditional method, however, is to mesh the graft. Meshed grafts usually also have enhanced reliability of engraftment because the fenestrations allow for egress of wound fluid and excellent contour match-ing of the wound bed by the graft. The fenestrations in meshed grafts must epithelialize by secondary | Surgery_Schwartz. have improved chances of complete engraft-ment, or “taking,” as they contain mostly epidermis, which has low metabolic demands, in contrast to thicker grafts that contain more dermis with greater metabolic needs.A variety of techniques have been described to maximize the surface area that can be covered by harvested skin amount while minimizing the size of the donor site.5 One approach is to process the harvested skin into micrografts using devices spe-cially designed for this purpose in the operating room. Another method is fractional skin harvesting, which involves harvesting a large number of full-thickness skin tissue columns that are then seeded onto the wound surface. The traditional method, however, is to mesh the graft. Meshed grafts usually also have enhanced reliability of engraftment because the fenestrations allow for egress of wound fluid and excellent contour match-ing of the wound bed by the graft. The fenestrations in meshed grafts must epithelialize by secondary |
Surgery_Schwartz_12997 | Surgery_Schwartz | engraftment because the fenestrations allow for egress of wound fluid and excellent contour match-ing of the wound bed by the graft. The fenestrations in meshed grafts must epithelialize by secondary intention from the sur-rounding graft skin. The major drawbacks of meshed grafts are poor cosmetic appearance and high rates of secondary contrac-tion. Meshing ratios used usually range from 1:1.5 to 1:6, with higher ratios associated with magnified drawbacks related to meshing. For any case, a decision to mesh the graft must be balanced against the disadvantages. Other differences between thin and thick STSGs include final durability, pigmentation, and tendency to desiccation of the final result. The distinguishing characteristics of skin grafts types based on thickness are sum-marized in Fig. 45-13.STSG donor sites heal by regeneration from dermal and epidermal elements remaining in the harvest site. Recesses between dermal papillae projecting into the dermis are lined by basal cells. | Surgery_Schwartz. engraftment because the fenestrations allow for egress of wound fluid and excellent contour match-ing of the wound bed by the graft. The fenestrations in meshed grafts must epithelialize by secondary intention from the sur-rounding graft skin. The major drawbacks of meshed grafts are poor cosmetic appearance and high rates of secondary contrac-tion. Meshing ratios used usually range from 1:1.5 to 1:6, with higher ratios associated with magnified drawbacks related to meshing. For any case, a decision to mesh the graft must be balanced against the disadvantages. Other differences between thin and thick STSGs include final durability, pigmentation, and tendency to desiccation of the final result. The distinguishing characteristics of skin grafts types based on thickness are sum-marized in Fig. 45-13.STSG donor sites heal by regeneration from dermal and epidermal elements remaining in the harvest site. Recesses between dermal papillae projecting into the dermis are lined by basal cells. |
Surgery_Schwartz_12998 | Surgery_Schwartz | 45-13.STSG donor sites heal by regeneration from dermal and epidermal elements remaining in the harvest site. Recesses between dermal papillae projecting into the dermis are lined by basal cells. These cells migrate across the wound surface and Figure 45-13A. Skin grafts categorized based on thickness.ThinIntermediateSplit skinThickFull thicknessskinABrunicardi_Ch45_p1967-p2026.indd 197501/03/19 6:26 PM 1976SPECIFIC CONSIDERATIONSPART IIDermal content1° contraction2° contractionEngraftmentDurabilityPigmentationResist desiccationRecipient bedAppearanceSTSG(thin) ++++++++++++++++++++++++++++++++++++++++++++++++++++++STSG(thick)FTSGBFigure 45-13B. Characteristics of skin grafts.reepithelialize it. During this process, the donor site must be kept moist and free of bacterial contamination. Depending on the thickness of the graft, uncomplicated donor site epitheliali-zation typically is complete in 2 weeks. In most cases, it should be protected from mechanical shear and drying until the | Surgery_Schwartz. 45-13.STSG donor sites heal by regeneration from dermal and epidermal elements remaining in the harvest site. Recesses between dermal papillae projecting into the dermis are lined by basal cells. These cells migrate across the wound surface and Figure 45-13A. Skin grafts categorized based on thickness.ThinIntermediateSplit skinThickFull thicknessskinABrunicardi_Ch45_p1967-p2026.indd 197501/03/19 6:26 PM 1976SPECIFIC CONSIDERATIONSPART IIDermal content1° contraction2° contractionEngraftmentDurabilityPigmentationResist desiccationRecipient bedAppearanceSTSG(thin) ++++++++++++++++++++++++++++++++++++++++++++++++++++++STSG(thick)FTSGBFigure 45-13B. Characteristics of skin grafts.reepithelialize it. During this process, the donor site must be kept moist and free of bacterial contamination. Depending on the thickness of the graft, uncomplicated donor site epitheliali-zation typically is complete in 2 weeks. In most cases, it should be protected from mechanical shear and drying until the |
Surgery_Schwartz_12999 | Surgery_Schwartz | Depending on the thickness of the graft, uncomplicated donor site epitheliali-zation typically is complete in 2 weeks. In most cases, it should be protected from mechanical shear and drying until the new skin matures with epidermal and dermal thickening and reac-tivation of sebaceous and sweat glands. Part of managing the donor site includes minimizing pain. Some recommended treat-ments include (a) subcutaneous anesthetic injection of adren-aline-lidocaine; (b) ice application; (c) topical agents such as lidocaine and bupivacaine; and (d) hydrocolloidand polyure-thane-based wound dressings accompanied with fibrin sealant.6 Maintaining air-tight coverage using transparent adhesive film dressing can protect the donor site during reepithelialization and minimize pain.Full-Thickness Grafts. By definition, full-thickness skin grafts include the epidermis and the complete dermis. When harvesting and preparing this type of skin graft, the surgeon must carefully remove any retained | Surgery_Schwartz. Depending on the thickness of the graft, uncomplicated donor site epitheliali-zation typically is complete in 2 weeks. In most cases, it should be protected from mechanical shear and drying until the new skin matures with epidermal and dermal thickening and reac-tivation of sebaceous and sweat glands. Part of managing the donor site includes minimizing pain. Some recommended treat-ments include (a) subcutaneous anesthetic injection of adren-aline-lidocaine; (b) ice application; (c) topical agents such as lidocaine and bupivacaine; and (d) hydrocolloidand polyure-thane-based wound dressings accompanied with fibrin sealant.6 Maintaining air-tight coverage using transparent adhesive film dressing can protect the donor site during reepithelialization and minimize pain.Full-Thickness Grafts. By definition, full-thickness skin grafts include the epidermis and the complete dermis. When harvesting and preparing this type of skin graft, the surgeon must carefully remove any retained |
Surgery_Schwartz_13000 | Surgery_Schwartz | Grafts. By definition, full-thickness skin grafts include the epidermis and the complete dermis. When harvesting and preparing this type of skin graft, the surgeon must carefully remove any retained subcutaneous tissue from the deep surface of the dermis in order to maximize the poten-tial for engraftment. Full-thickness grafts are associated with the greatest amount of primary contraction, the least amount of secondary contraction, the highest durability, and ultimately the best cosmetic appearance. As a result, they are frequently used in reconstructing superficial wounds of the face and the hands. These grafts require clean, well-vascularized recipient beds free of bacterial colonization, previous irradiation, or fibrous wound tissue. They also work poorly in wounds associated with previ-ous radiation treatments in cancer patients. The harvest site for an FTSG must be closed primarily because no skin elements remain in the area of harvest.Skin Substitutes. Skin substitutes are | Surgery_Schwartz. Grafts. By definition, full-thickness skin grafts include the epidermis and the complete dermis. When harvesting and preparing this type of skin graft, the surgeon must carefully remove any retained subcutaneous tissue from the deep surface of the dermis in order to maximize the poten-tial for engraftment. Full-thickness grafts are associated with the greatest amount of primary contraction, the least amount of secondary contraction, the highest durability, and ultimately the best cosmetic appearance. As a result, they are frequently used in reconstructing superficial wounds of the face and the hands. These grafts require clean, well-vascularized recipient beds free of bacterial colonization, previous irradiation, or fibrous wound tissue. They also work poorly in wounds associated with previ-ous radiation treatments in cancer patients. The harvest site for an FTSG must be closed primarily because no skin elements remain in the area of harvest.Skin Substitutes. Skin substitutes are |
Surgery_Schwartz_13001 | Surgery_Schwartz | previ-ous radiation treatments in cancer patients. The harvest site for an FTSG must be closed primarily because no skin elements remain in the area of harvest.Skin Substitutes. Skin substitutes are typically types of extra-cellular matrices that are often acellular in nature and are either human-derived (allografts), animal-derived (xenografts), tissue engineered, or a combination of the three.7 These substitutes most often are employed to replace lost dermal and/or epider-mal skin layers resulting from burns, trauma, and other super-ficial injuries to the outer skin layers. While a complete review of all of these commercially available materials is beyond the scope of this chapter, the benefits and applications of these use-ful adjuncts is growing, and they been have shown to play an important role in current as well as future reconstructive, regen-erative, and restorative measures for tissue and skin replace-ment. Essentially, they act similarly to grafts as they rely on | Surgery_Schwartz. previ-ous radiation treatments in cancer patients. The harvest site for an FTSG must be closed primarily because no skin elements remain in the area of harvest.Skin Substitutes. Skin substitutes are typically types of extra-cellular matrices that are often acellular in nature and are either human-derived (allografts), animal-derived (xenografts), tissue engineered, or a combination of the three.7 These substitutes most often are employed to replace lost dermal and/or epider-mal skin layers resulting from burns, trauma, and other super-ficial injuries to the outer skin layers. While a complete review of all of these commercially available materials is beyond the scope of this chapter, the benefits and applications of these use-ful adjuncts is growing, and they been have shown to play an important role in current as well as future reconstructive, regen-erative, and restorative measures for tissue and skin replace-ment. Essentially, they act similarly to grafts as they rely on |
Subsets and Splits